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a Amok L IFIED PROGRAM CONSOLIDATED FOTM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One fon.per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11,111.IV,and IV 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: 430.. 1 DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1• BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3• USA#68153 BUSINESS SITE ADDRESS 103 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)] _C6 __❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a. ..__................... ....._..._.._...._.... .....................__................................__....--_"___------ CONTENTS PETROLEUM: ® la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440• ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Spccik): 440a. __...................................................................................................__... - ..................... ._........__._......_.. .._................._.........................._.. ............_...- --..._....._ ....._..........._..._............ _.._. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHERNON-PETROLEUM(Specify): 4406. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL [195.UNKNOWN 443• PRIMARY CONTAINMENT E] 1.STEEL - ® 3.FIBERGLASS ❑ 6.INTERNAL BLn DDI;K - _-- Y - ❑ 7.STEEL+INTERNAL LINING; ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444a. _...._._.. ._ P fY) SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED �5• ❑ . 90.NONE ❑ 95.UNKNOWN [199.OTHER(Specify): 445a. _ -.............................'---....... ---...... _..._._....._._ _.... ......._..__. 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 [:14.SAFE SUCTION[23 CCR§2636(a)(3)] 458. - --_..........._......_....---.._....__.......................................-_-..__...._........._._....__................_... PRIMARY CONTAINMENT 1:11.STEEL ® 4.FIBERGLASS [18.FLEXIBLE - ❑ 10.RIGID PLASTIC 464. ❑ 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 464d. VI. VENT,VAPOR RECOVERY (VR) AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464e. 464el. VENT SECONDARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46441. -----'-- - ------'--...............-__._.. --.._.._.....-.....__ .......-........__.__ - _......... - _-- VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Speci464g. VR SECONDARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLAti> ❑ I0.RIGID PI A"H( ❑ 90.NONE ❑ 99.OTHER(Specify): 464h. ) 464hl. VENT PIPING TRANSITION SUMP TYPE ❑ I SINGI If\\nl I ❑ DOUBI I \\ v1 ® 90.NONE 4641. ... ............... _ __......�. _-_ _ __.__._.........._........................................_.........__..._..-__..._ RISER PRIMARY CONTAINMENT ® 1.STEEL [14.FIBERGLASS ❑ l0.RIGID PLASTIC' ❑ 90.NONE [199.OTHER(Specify): 464.. 464j1. RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464k. 464kl. FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a. ..............._..._........................._....._....__......................................._................_......_...__.._.........----..........................__._..__................._.__._........_..._...... --_._............_ ...._.......................__...............................................................__.._-..............__......_.....__............................................................_......_..................... CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696: VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST sys m is compatible with the hazardous substance stored and that the information provided herein is true, acc and► full com ince with legal requirements. APPLICANT SI ATURE DATE 11/12/2010 470 APPLICANT NXMEJMmoltrjC, Z�� 471. APPLICANT TITLE Code Compliance Officer 47' UPCF UST-B Rev.(12/2007)-1/2 �%wN.unidocs.org