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AOi J&MED PROGRAM CONSOLIDATED FO co UNDERGROUND STORAGE CONSOLIDATED OPERATING ERMIT APPLICATION-TANK ORMATION (one form per UST) TYPE OF ACTION (Check one item only. For a UST clasnne or removal,complete only this section and Sections I,A,ID IV and LY below) 430. ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4301 1 DATE EXISTING UST DISCOVERED: 4306 L FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ _ I BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3 Flag City Chevron BUSINESS SITE ADDRESS 103 CITY 104 6421 Capitol Ave I Lodi U. TANK DESCRIPTION TANK ID# 432• TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. •{�� _706SOS540 Xerxes ® 1.A STAND-ALONE TANK Complete one page for each 'T V 2.ONE IN A COMPARTMENTED UNIT compartment in the unit. DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437 10,000 1 III. TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Ic.AVIATION FUELING 439. ❑ 3.CHEMICAL MMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(todudea Used Olt) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439x. ...................... CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.ItIIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440. ® 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440x. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM ): 4406. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.RUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444x. SECONDARY CONTAINMENT ❑ I.STEEL ®3.FrBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER( 4451. OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.HALL FLOAT ® 3.FILL TUBE SHPT-OFF VALVE 452 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 99.OTHER Qe SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(1x3)] ass PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE _ ❑ 95.UNMOWN ❑ 99.OTHER(Specify): 464a. SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4640. PIPINGn URBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 90.NONE 464d. VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT [31.STEEL ® 4.FIBERGLASS [310.RIGID PLASTIC El 90.NONE ❑ 99.OTHER(Specify): 4641 VENT SECONDARY CONTAINMENT E31.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE E399.OTHER(Specify): 46411. VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OT M(Specify): 4464s- VR aVR SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464hj VENT PIPING TRANSITION SUMP TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464i. RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): =,I- 464. RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464k] FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATEIBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469x. CONSTRUCTION MATERIAL [31.STEEL. ® 4.FIBERGLASS ® 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.L90LATI0N 448. UL APPLICANT SIGNATURE CERTIFICATION: i certify that this UST system is compatible with the hazardous substance stored sad that the information provided herein is true, accurs and in M compliance uirements. APPLICANT SIGNATURE - � Q DATE t� 4�0. APPLICANT NAME(print) 1 471 APPLICANT TITLE 472. UPCF IJS'I-B Rev.(12/2007)-1/1 www.unidoes.org