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IFIED PROGRAM CONSOLIDATED FOIM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item onli. For a UST closure or removal,complete only this section and Sections 1,11.111,IV,and IX belox) 430• ❑ I.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. 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. USA#68153 BUSINESS SITE ADDRESS 103' CITY 104. 2448 WEST KETTLEMAN LANE I LODI IL TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER a3s. TANK CONFIGURATION:THIS TANK IS 434. 68153 PREMIUM(91) 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 ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOW_N _ ❑ 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(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,UNKNOWN443. EN1 PRIMARY CONTAINMENT. ❑ .STEEL ® 3"'."'F"I BERG LAS"_S ❑ 6.INTERNAL BLADDER _ ❑ 7.STEEL,INTERNAL LINING [195.UNKNOWN ❑ 99.OTHER(Specify): 444a. SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445x. _..._......................................_..__.................. _ - --- ....... ORFIAL VELL 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§2636(aX3)] PR458. .......-.IMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ FLEXIBLE ❑ 10.RIGID PLASTIC aha. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Spec i ty): 464a. SECONDARY CONTAINMENT ❑ 1.STEEL_ ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. ❑ 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 ❑ I S111-1 ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464e1. ........................ _- _._ _._...._ -_..__. -.. -.. -- - _. VENT SECONDARY CONTAINMENT ❑ 1.S 1111 ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464f ..__..._.._............_.._...-.--__........_....._--....._..............................____.. __......-_..._-..........._.............. 464t1. VR PRIMARY CONTAINMENT ❑ 1.STEF1 E 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464ag. .....---'--.. ..._....... .... _.-_..---_......_..-- _.._................._ ....4.._.._ VR SECONDARY CONTAINMENT ❑ S I I I 1 ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464h1. __.-__-..............._................------.-_....._........._..__................_....._.._..................._.__...._.........._...........--__............_....._................_.._---.._...._...._......_...................__.. _-_- -'- - ---- ......._........_.. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 4641. ......_....._..............................................._..._..___.._.-...--'--._..-...__._.......----.... _..__..._.__..__....... .__......_... ._ _ ..._.._. ..---- ----- ...._.._..._....................................._......................--...._......_................... . 464x. RISER PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ ]0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): i§iA.,_•••• ......................................................._._.__................................._._................................._._............._...._._........................................................_._.___......_...-._........._.....__- ._._.........__-..--_.._..---_.._--'--....___.......-........___._.................._.._.. 464k. RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464k1 FILL COMPONENTS INSTALLED - _®-1.SPILL BUCKET.............._._._............._._._._._......_...__...__...._._-_..-'----'------ -.__-...._...._..._..............._.................._............... ® 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CON........................................-.............................................._....._...._...................................-......................................._.__.._._....._..............................._.............._.. -...__.._......... -._.... _..... ......._._...........................................................................................................4..9......... CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.01111 R(Specify) 4696. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, rate,and in full qoml4ance with legal requirements. APPLICANT SI ATU DATE 11/12/2010 470 APPLICANT NA n-0 Eric 471. APPLICANT TITLE Code Compliance Officer 472 UPCF UST-B Rev.(12/2007)-1/2 vlww.unidocs.org