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IFIED PROGRAM CONSOLIDATED FOIM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (one fonn per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11.111,1V,and IXbelow) 430. ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ® S.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430.. I DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agencv Use Only) _ _ 1 BUSINESS NAME(Sane as Facility Name or DBA-Doing Business As) 3. USA#68153 BUSINESS SITE ADDRESS 103. CITY 104. 2448 WEST KETTLEMAN LANE LODI H. TANK DESCRIPTION TANK ID# 43-• TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. 68153 DIESEL 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 ❑ ]c.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.UNKNOWN ❑ 99.OTHER(Specify): 439a. ----......_..........__._....................._......._...._...._--_..__.._----_......................._....._.._.... _ - ..... CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ la MIDGRADE UNLEADED ❑ ]b.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(Specify): 440b. 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): 444a. ......................._.._..._................... ............................................................---...................__._....._....__ .............._..-_--_....................................._......_._..._- ........................_..............._..... . SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a. _............................_.. ----._.._.........._........... ............_........ - - _..._.._..__._._ ............ OVERFILL PREVENTION ® I.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 _ _ CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458. -----_._._-.. .... ...... ............................ PRIMARY CONTAINMENT ❑ I STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE_ ❑ 95.UNKNOWN ❑_ 99.OTHER(Specify): 464a. ----......_........_......._.. --... .. _ _ _.............-_........ ..._._.. SECONDARY CONTAINMENT ❑ I.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 ❑ I.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464e1. _ _ _......---...........__._.._.. ... .... ....................._._....--'----.__..._.__.._.__............_____............_....._._........._....................................-..............______..........................................._.._._...___-...______....... 464f. VENT SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464fl. _-._..._..._. _. ... . --- _ -___._.._.._._........................_._-..---...._.............._.....__._._.._._.._............._..........................._....._._.. -� - -- -._.....-..._._... __._......_. .. ......... ...... .. ... ... ... 4648. VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ I0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4641 --........_.....---.....__ _ _.._..__.. _...........................- .._-._ __._._.........._ _...... -- -- - VR SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464h1. _....................-__._---------_._..... - - -- - ... VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 1xu 131 I NAI 1 ® 90.NONE a6at. ....................._....._.............--- _ _._. _._._..__..__.._..__..........__............._.......--._............._..._......_ ......... - ----- .-._............ ..... ._ RISER PRIMARY CONTAINMENT ® L STEEL ❑ 4.FIBERGLASS ❑ 10.kI(.il)PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464j. 4641.._... RISER SECONDARY CONTAINMENT ❑ 1.STEEL [1464A41.4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 614 FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP alfa-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL [12.DOUBLE WALL ❑ 3.NO DISPENSERS [190.NONE 469a. _......_..._._._._.........................._........._......- -----..._.. .._.._....__........................................_..._..__.._.._... -- -- -....__................_........._........._..................._.................__._.................. CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c. 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 system is compatible with the hazardous substance stored and that the information provided herein is true, a nd in full compftce with legal requirements. APPLICANT SDATE 11/12/2010 470 APPLICANT E( r' Erl Ze 471. APPLICANT TITLE Code Compliance Officer 472 UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org