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AdEL AOL NIFIED PROGRAM CONSOLIDATED UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (OneformperUST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 4 II,111,IV,and IX below) 430. ❑ L 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: 430a. DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY 1D#(Agency Use Only) 1 BUSINESS NAME(Same as Facilitv Name or DBA-Doing Business As) 3. USA#68153 BUSINESS SITE ADDRESS 10" CITY 104. 2448 WEST KETTLEMAN LANE LODI II. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. 68153 REGULAR(87) DOUBLEWALL FRP ® 1.A STAND-ALONE TANK Complete one page for each ❑ 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 ❑ lc.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] __ _❑__6.O_TH_ER G_EN_ERATO_R FUEL__ -❑ 95.UNKNOWN _ ❑ 99.OTHER(Specify): 439a. CONTENTS PETROLEUM: y ® la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ ]b.PREMIUM UNLEADED 4407 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440a. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT ❑ I.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER -_- 444. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444a. SECONDARY CONTAINMENT ❑ L STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a. OVERFILL PREVENTION ® L AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ® 3.FILL TUBE SHUT-OFF VALVE W 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§2636(ax3)] 458. PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC aha. _ _______ ❑ 90.NONE_ ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a. SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. ❑ 90.NONE _ ❑ 95.UNKNOWN_ ❑ 99.OTHER(Specify): 464c. ......... ............ ........... . _ PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE VI. VENT, VAPOR RECOVERY (VR) AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC [190.NONE [199.OTHER(Specify): 464c. 464e1. VENT SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464fl. VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 44 __ VR SECONDARY CONTAINMENT [11.STEEL ® 4.FIBERGLASS [310.RIGID PLASTIC ❑ 90.NONE [199.OTHER(Specify): 46gj VENT PIPING TRANSITION SUMP TYPE - ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 464'' RISER PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464j._ 464'1. RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): k. 4464 . FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469x. ..........................._._...._..............__....__.._._._..._......__....._....._........................__._..._...--..-....._.._......._-.............................._..............__..........- ... -....- ....--- --....._.._.._..- --..............................._._...__..__...._-.._..._._.................___...........------- - .... - CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specif�) 469b. 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 446. IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this USTsy m is compatible with the hazardous substance stored and that the information provided herein is true, aec t and ull com ince with legal requirements. APPLICANT SI ATURE _- DATE 11/12/2010 470 APPLICANT N riC Z 471' APPLICANT TITLE Code Compliance Officer 472 11PCF IIST-BRev_(LU2M _-_IJ2- www.unidoes.org --- - -- --