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IFIED PROGRAM CONSOLIDATED FORM I ( ✓A TANK: TA0133204 PR#: PR0231332 UNDERGROUND STORAGE TANKS -TANK E 1 (L� FAC#: FA0003961 / l (two pages per tank) TYPE OF ACTION ❑ I NEW SITE PERMIT ❑ 4 AMENDED PERMIT5 CHANGE OF INFORMATION Page 2 of9 (Check only item only) ❑ ❑ 6 TEMPORARY SITE CLOSURE ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify reason-Por Jowl use only) (Specify reason-for local use only) ❑8 TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID: PR#: 1 LODI MUNI SERVICE CENTER 3 FA000396 t PR0231332 nT1 I I LOCATION WITHIN SITE(Optional) 1331 S HAM Ln,LODI 431 PHONE I.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#: 4 432 TANK MANUF 433 COMPARTMENTALIZED TANK E]Yes E]No 434 TA0133204 PERKI If"Yes",complete one page for each compartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACI NUMBER OF COMPARTMENTS 436 437 10,000 ADDITIONAL DESCRIPTION(For local use only) 436 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ® I.MOTOR VEHICLE FUEL ® la.REGULAR UNLEADED ❑ 2.LEADED ❑ 5.JET FUEL (I f marked complete Petroleum Type) ❑ Ib.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 6.AVIATION FUEL ❑ 2.NON-FUEL PETROLEUM ❑ Ic.MIDGRADE UNLEADED ❑4.GASOHOL ❑ 99.OTHER ❑ 3.CHEMICAL PRODUCT COMMON NAMEfrom Hazardous Materials Inventory rypage) 441 CAS#(from Hazardous Materials Inventory page) JJ' ❑ 4.HAZARDOUS WASTE (Includes Used Oil) ❑ 95.UNKNOWN M.TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ❑ 3.SINGLE WALL WITH ❑ 5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 441 (Check one item only) EXTERIOR MEMBRANE LINER ❑95.UNKNOWN ® 2.DOUBLE WALL ❑ 4.SINGLE WALL IN 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 ANK MATERIAL-secondary tank ❑ 1.BARE STEEL ❑3.FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 445 Click 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 ❑ RUBBER LINED 3EPDXY LINING 1. ❑ . 447 OR COATING ❑ 5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED (Check one item only) ❑ 2 ALKYD LINING ❑4 PHENOLIC LINING ® 6 UNLINED ❑99.OTHER (For local meanly) ) CORROSION E] I MANUFACTURING CATHODIC E] 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 446 DATE INSTALLED 449 );HTER 0ECTION IF APPLICABLE PROTECTION beck one item ody) ❑4 IMPRESSED CURRENT ❑ 99 OTHER C]2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLE450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apply) ❑ I SPILL CONTAINMENT ❑ 1 ALARM ❑ 3 FILL TUBE SHUT OFF VAL` ❑ 2DROP TUBE ❑ 2BALL ❑ 4EXEMPT ❑ 3 STRIKER PLATE FLOAT IV.TANK LEAK DETECTION(A description of the monitoring program shall be submitted to the local agency.) / SINGLE WALL TANK(Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ 1 VISUAL(EXPOSED PORTION ONLY) E] 5 MANUAL TANK GAUGING(MTG) (Check one item only) ❑ 2 AUTOMATIC TANK GAUGING(ATG) ❑ 6 VADOSE ZONE ❑ 1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 3 CONTINUOUS ATG ❑ 7 GROUNDWATER ®2 CONTINUOUS INTERSTITIAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING (SIR)BIENNIAL TANK TESTING E]3 MANUAL MONITORING ❑ 99 OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 1 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 ❑Yes ❑No UPCF(12/99 revised)