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-FIED PROGRAM CONSOLIDATED FORM TANK: TA0133208 PR#: PRO231332 UNDERGROUND STORAGE TANKS -TANK 1 �� FAC#: FA0003961 • a (two pages per tank) TYPE OF ACTION ❑ 1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE Page 8 of 9 (Check only item only) p fy tSpceity reason-for tont use only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (5 ec reason-for local toe only) ❑8 TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID: PR#: l LODI MUNI SERVICE CENTER 3 FA0003961 PR0231332 LOCATION WITHIN SITE(Optionaq 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#: W 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ❑No 434 TA0133208 N J MCCUTCHEON If"Yes",complete one page forachcompartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITM2,O LLONS 436 NUMBER OF COMPARTMENTS 437 0 ADDITIONAL DESCRIPTION(For local use only) t��0 G• 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE f 440 ® I.MOTOR VEHICLE FUEL ® la.REGULAR UNLEADED ❑ 2.LEADED ❑ 5.JET FUEL Ofmarked complete Petroleton Type) ❑ Ib.PREMIUM UNLEADED ❑3.DIESEL ❑ 6.AVIATION FUEL ❑ 2.NON-FUEL PETROLEUM ❑ lc.MIDGRADE UNLEADED ❑4.GASOHOL ❑ 99.OTHER ❑ 3.CHEMICAL PRODUCT COMMON NAME(from Harrrdous Materials Inventory page) 441 CAS#(from Hazardous Materials Inventory page) 44, ❑4.HAZARDOUS WASTE (includes Used 00) ❑ 95.UNKNOWN III.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 6�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 TANK MATERIAL-secondary tank ❑ I.BARE STEEL ❑ 3.FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 445 (Check one item only) ❑ 2.STAINLESS STEEL ❑4.STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTIBLE W/1001%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 446 DATE INSTALLED 44 OR COATING (Check one iteonly) ❑ 2 ALKYD LINING E] 4 PHENOLIC LINING ® 6 UNLINED ❑99OTHER m (For local use Doty) OTHER CORROSION ❑ I MANUFACTURING CATHODIC ❑ 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 44s DATE INSTALLED 441 PROTECTION IF APPLICABLE PROTECTION (Check one item only) E] 4 IMPRESSED CURRENT E]99 OTHER F1 2 SACRIFICIAL ANODE (For local use only) S ILL AND OVERFILL YEAR INSTALLE450 TYPE(loal use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 Check all that apply) ❑ I SPILL CONTAINMENT ❑ 1 ALARM ❑ 3 FILL TUBE SHUT OFF VAL` ❑ 2 DROP TUBE ❑ 2 BALL ❑ 4 EXEMPT ❑ 3 STRIKER PLATE FLOAT IV.TANK LEAK DETECTION(A description of the monitoring program shall be submitted to the loal 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 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 ❑ 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? 457 ❑ Yes ❑ No UPCF(12/99 revised)