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bwc. 4 IFIED PROGRAM CONSOLIDATED FOR I TANK: TA0133208 1 PR#: PR0231332 UNDERGROUND STORAGE TANKS - TANK i 12v FAC#: FA0003961 y�y/ a (two pages per tank) Page 8 of 9 TYPE OF ACTION ❑ I NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF NFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check only item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify ream-for local we only) (Specityrea+on-forlocaltxonly) ❑8 TANK REMOVED 430 BUSINESS NA.VIE(Same as FACILITY NAME or DBA-Doing 8wincss As) 3 FACILITY ID: PR#: LODI MUNI SERVICE CENTER FA0003961 PR0231332 LOCATION WITHIN SITE(Optional) 1331 S HAM Ln,LODI 431 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.) '�1I TANK ID# Tank#: W 431_ TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ❑No 434 / I TA0133208 N J MCCUTCHEON If"Yes".complete otic page for each compartment. U DATE INSTALLED(YEAR/NIO) 435 TANK CAPACITGALLONS 436 NUMBER OF COMPARTMENTS 417 r20 0 ADDITIONAL DESCRIPTION i For local we only) `0 t 6 6 A 438 1 1k II.TANK CONTENTS TANK USE 419 PETROLEUM TYPE f 440 ® I.MOTOR VEHICLE FUEL ® la.REGULAR UNLEADED ❑ 2.LEADED ❑ 5.JET FUEL (lfmarkcd complete Petrolaun Type ❑ Ib.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 6.AVIATION FUEL ❑ 2.NON-FUEL PETROLEUM ❑ Ic.MIDGRADE UNLEADED ❑ 4.GASOHOL ❑ 99.OTHER ❑ 3.CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials In.rntory page) 44l CAS#(fr om Hazardous Materials Inventory page) 142 ❑4.HAZARDOUS WASTE (Includes Used Oil) ❑ 95.UNKNOWN 111.TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL ❑ 3.SINGLE WALL WITH ❑ 5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑ 95.UNKNOWN 66 DOUBLE WALL ❑ 4.SINGLE WALL IN VAULT ❑ 99.OTHER TANK MATERIAL-primary tank ® 1.BARE STEEL ❑ FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN j{4 (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 tankI.BARE STEEL ❑ 3.FIBERGLASS/PLASTIC ❑ S.CONCRETE ❑ 95.UNKNOWN 145 (Check one item only) ❑ 2.STAINLESS STEEL ❑ 4.STEEL CLADW/FIBERGLASS ❑ 8.FRP COMPTIBLEW/100°/METHANOL REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑ 99.OTHER ❑ 5.CONCRETE 44- TANK INTERIOR LINING ❑ 1.RUBBER LINED ❑ 3.EPDXY LINING ❑ 5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED OR COATING ❑ 99.OTHER (Check one item only) ❑ 2 ALKYD LINING E] 4 PHENOLIC LINING ® 6 UNLINED (For local use only) OTHER CORROSION ❑ I MA 'UFACTURING CATHODIC F13 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE P' IFICIAL ANODE CTION IChcck orte item only) F14IMPRESSED CURRENT C] 99OTHER (For local we only) SACR SPILL AND OVERFILL YEAR INSTALLE450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 Check all that apply) E] I SPILL CONTAINMENT E] I ALARM ❑ 3 FILL TUBE SHUT OFF VAL` ❑ 2DROP TUBE ❑ 2BALL E] 4EXEMPT ❑ 3 STRIKER PLATE FLOAT V.TA N K LEAK DETECTION(A description of the nwnitoring 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 ❑ 1 VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Check one item only) ❑ ❑ 2 AUTOMATIC TANK GAGGING(ATG) ❑ I VISUAL(SINGLE WALL IN VAULT ONLY)6 VADOSE ZONE i ❑ 3 CONTINUOUS ATG ❑ 7 GROUNDWATER 2 CONTINUOUS INTERSTITIAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING ❑3 MANUAL MONITORING (SIR)BIENNIAL TANK TESTING ❑ 99 OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR MO DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 4i" ❑ Yes ❑ No UPCF(12/99 revised)