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oYsc. y s �,. IFIED PROGRAM CONSOLIDATED FOR? ( TANK: TA01332 77 PR#: PR0231332 UNDERGROUND STORAGE TANKS - TA I FAC#: FA0003961 ll L9 (two pages per tank) I FYI Page 6 of 9 TYPE OF ACTION ❑ I NEW SITE PERMIT F-14 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check only item only) ❑ 7 PERMANENTLY CLOSED ON SITE (Specify reason-for local use only) (Specify reason-for local use only) ❑ 3 RENEWAL PERMIT ❑ 8 TANK REMOVED +°o BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Btuiness As) FACILITY 1D: PR#: LODI MUNI SERVICE CENTER 3 FA0003961 PR0231332 LOCATION WITHIN SITE IOptional) 1331 S HANI Ln.LODI 4; PHONE 1.TANK DESCRIPTION(A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID# Tank#: 7 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ❑No 434 TA0133207 PERKINS If"Yes".complete one page for each compartment. DATE INSTALLED(YEAR/:MO) 4;; TANK CAPACITY t S 436 NUMBER OF COMPARTMENTS 41- 5 000 ADDITIONAL DESCRIPTION(For local use only, +i Il.TANK CONTENTS TANK USE 4}9 PETROLEUM TYPE 440 ® I.MOTOR VEHICLE FUEL ❑ la.REGULAR UNLEADED ❑ 2.LEADED ❑ 5.JET FUEL (If marked complete Petroleum Type) ❑ Ib.PREMIUMUNLEADED ® 3.DIESEL ❑ 6.AVIATION FUEL ❑ 2.NON-FUEL PETROLEUM ❑ Ic.MIDGRADE UNLEADED ❑ 4.GASOHOL ❑ 99.OTHER ❑3.CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials Inventory page) 441 CAS#(from Hazardous Materials Inventory page) 441 ❑4.HAZARDOUS WASTE (Includes Used Oil) ❑95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ❑3.SINGLE WALL WITH ❑ 5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 4+' (Check one item only) EXTERIOR MEMBRANE LINER ❑ 95.UNKNOWN ® 2.DOUBLE WALL ❑4.SINGLE WALL M VAULT ❑ 99.OTHER TANK MATERIAL-primary tank ® 1.BARE STEEL ❑ FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 444 (Check one item only) ❑ 2.STAINLESS STEEL ❑ STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑ 99.OTHER TANK MATERIAL-secondary tank I.BARE STEEL ❑ 3.FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN ;4; Check one item only) ❑ 2.STAINLESS STEEL ❑ 4.STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑ 99.OTHER ❑ 5.CONCRETE TANK INTERIOR LINING ❑ 1.RUBBER LINED ❑ 3.EPDXY LINING ❑ 5.GLASS LINING ❑95.UNKNOWN +46 DATE INSTALLED OR COATING (Check one item only) 2 ALKYD LINING 4 PHENOLIC LINING 6 UNLINED ❑ 99.OTHER ❑ ❑ ® (For local use only) OTHER CORROSION ❑ 11 NL'FACTURING CATHODIC 440 PROTECTION IF APPLICABLE P OTECTION ❑ 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 41g DATE INSTALLED ❑ 4 IMPRESSED CURRENT ❑99 OTHER (Check one item only) 2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLE450 TYPE(local we only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check alllhat apply) ❑ I SPILL CONTAINMENT ❑ l ALARM ❑ 3 FILL TUBE SHUT OFF VAL' ❑ 2 DROP TUBE ❑ 2 BALL ❑ 4 EXEMPT ❑ 3 STRIKER PLATE FLOAT - 0 R'.TANK LEAK DETECTION(.A description of the mooimring program shall be submitted to the local agency.) IF SINGLE WALL TANK(Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ I VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Check one item only) ❑ 2 AUTOMATIC TANK GAUGING(ATG) ❑ 6 VADOSE ZONE ❑ I VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 3 CONTINUOUS ATG ❑ 7 GROUNDWATER ®2 CONTINUOUS INTERSTITIAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑ STANK TESTING ❑3 MANUAL MONITORING (SIR)BIENNIAL TANK TESTING ❑ 99 OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MOIDAY) +55 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL:' 45- ❑ Yes ❑ No UPCF(12/99 revised)