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-'NIFIED PROGRAM CONSOLIDATED F UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK FORMATION (One form per UST) TYPE OF ACTION (Check one item only. For a UST clan re or removal,complete only this section and Sections I,U Ill,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: 430e I DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3 Flag City Chevron BUSINESS SITE ADDRESS 103. CITY IN 6421 Capitol Ave I Lodi H. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. Xerxes [3 2.ONE IN STAND-ALONE COMPARTMENTED UNIT comport Complete one page For each moot in the unit DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436• NUMBER OF COMPARTMENTS IN THE UNIT 437 12,000 1 III. TANK USE AND CONTENTS TANK USE ® la MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ lc.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(lecrdes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ 1a.REGULAR UNLEADED ❑ ]c.MIDGRADE UNLEADED ® lb.PREMIUM UNLEADED 44 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Spwtfy): 410a. NON-PETROLEUM:0 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM ): 4406. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444L SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445• ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445x. OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ® 3.FILL.TUBE SHUT-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 460 SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR 12636(ex3)] 458. PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464x. SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 46415 13 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ® 2.DOUBLE WAIL ❑ 90.NONE 4644 VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ to.RIGID PLASTIC ❑ 90.NONE [399.OTHER(Specify): 464 1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL, N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 44G64f. VR PRIMARY CONTAINMENT ❑ 1.STEEL, N 4.FIBERGLASS [310.RIGID PLASTIC [390.NONE [399.OTHER(Specify): 4640.4n B VR SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4464 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464i RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4640j RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 44"k. . FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP aslac:" VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469x. CONSTRUCTION MATERIAL ❑ L STEEL ® 4.FIBERGLASS ® 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469e VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448 UL APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate,and in fullcompliance with legal requirements. APPLICANT SIGNATURE DATE 470 APPLICANT NAME(Print) , 471• APPLICANT TITLE 472. UPCF UST-B Rev.(12/2007)-IA www.unidocs.org