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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form Per UST) TYPF OF ACTION (Check one item only Fora UST closure or removal,complete only this section and Sections[. 11114 IV.and/X below) 430 ❑ L NEW PERMIT ❑ 3.RENEWAL PERMIT ® 5 CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.LIST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE.UST PERMANENTLY CLOSED. 430a DATE EXISTING UST DISCOVERED: 430b L FACILITY INFORMATION FACILITY ID#(Agency Use Only) t BUSINESS NAME(Same as Facihi),Name or DBA-Doing Business As) USA/Tesoro 68152 BUSINESS SITE ADDRESS Etl3 CITY 104 401 W. Kettleman Lane Lodi II. TANK DESCRIPTION 'TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 1 � �� TCLLSCO ❑ 1 A STAND-ALONE-TANK Complete one page for each 2 ONE INA COMPARTMENTED com ment in the unit ❑ R MEN'D'ED UNIT Pon DATE UST SYSTEM INSTALLED 435 TANK CAPACITY TY IN GALLONS 436, NUMBER OF COMPARTMENTS IN THE UNIT 437- 1998 14,000 1 III. TANK USE AND CONTENTS TANK USE ® la MOTOR VEITICI_E FUELING ❑ Ib.MARINA FUELING ❑ Ic AVIATION FUELING 439 ❑ 3 C'HL-MICAL PRODUCT STORAGF ❑ 4.HAZARDOUS WASTE ilncludes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL)Hsc§29231 9t<)) ❑ 6.OTHER GENERATOR FUEL ❑ 95 UNKNOWN ❑ 99 OTHER(Specify). CONTENTS PETROLEUM ® 13 REGULAR UNLEADED ❑ IcMIDGRADE UNLEADED ❑ Ib PREMIUM UNLEADED 4" ❑ 3.DIESEL ❑ 5 JET FUEL ❑ 6.AVIATION GAS ! ❑ 8.PETROLEUM BLEND FUEL ❑ 9 OI HER PETROLEUM(Specify). 440a NON-PETROLEUM:❑ 7.USED 01-L ❑ 10 t.THANOL ❑ 11.OTHER NON-PETROLEUM(Specify) 3406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL N 2.DOUBLE WALL- ❑ 95.UNKNOWN 443 PRIMARY CONTAINMEW[ ® I.STEEL ❑ 3.FIBERGLASS 't-j-6.INTERNAL BLADDER 444 - ❑ 7 STEEL+INTERNAL LINING ❑ 95 UNKNOWN 444& - ..-.___._ .. CI 99 OTHER(Specify.): SECONDAKY CONTAINMENT ❑ I.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ® 7-JACKETED 445 ❑ 90 NONE ❑ 95 UNKNOWN ❑99 OTHER(Specify): 4453 OVERFILL PREVENTION ❑ 1 AUDIBLE&VISUAL ALARMS ❑ 7 9ALL 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 ❑ I.SINGLE WALL ® 2 DOUBLE WALL ❑ 99 OTHER 460 SYSTEM T YPI. -® 1 PRESSURE: ❑ 2 GRAVITY ❑ I CONVENTIONAL SUCTION ❑ 4 SAFE.SUCTION(3 CCR§2a36(a)(3)) 458 PRIMARY CONTAINMENT ❑ 1.STEEL ® !.FIBERGLASS ❑ S.FLEXIBLE ❑ 10 RIGID PLASTIC _ 464 _.__.._.❑ 90 NONE ..._.___ ❑ 95 UNKNOWN ❑ 99 43 OTHER(Specify) 46 . SECONDARY CONTAINMENT ❑ i.STEEL ® 4.FIBERGLASS ❑ 8 FLEXIBLE ❑ 10.RIGID PLASTIC 46 1 4b ❑ 90 NONE ❑ 95.UNKNOWN ❑ 99 OTHER(Specify) 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ® L SINGLE WALL ❑ 2 DOUBLE WALL ❑ 90.NONE 4541. VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT [3I STEEL ® 0.FIBERGLASS [3 10. 464,RIGID PLASTIC ❑ 90 NONE ❑ 99.OTHER(Specify)- 464e1 VENT SECONDARY CONTAINMENT ❑ I STEEL ❑ 4.FIBERGLASS ❑ 10 RIGID PLASTIC ® 90.NONE. ❑ 99 OTHER(Specify): 4464 VR PRIMARY CONTAINMENT ❑ I STEEL ® 4 FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90.NONE ❑ 99 OTHER(Spectty➢ & -- - _..._._ - _ ,....__... ..__ . ... VR SECONDARY CONTAINMENT ❑ ! STEEL ❑ 4-FIBERGLASS ❑ 10 RIGID PLASTIC ® 90.NONE ❑ 99 OTHER(Specify): 4644641. --�- --__._ _ _._._ -----.___._...........__.____................- _- VENT PIPING TRANSITION SUMP TYPE ❑ L SINGLE'WALL ❑ 2.DOUBLE WALL ® 90.NONE 464;. - _. ......... .. _ ._._.._. ...-.-- -- - - _ _...._.._. ...___ RISER PRIMARY CONTAINMENT ® ( STEEL ❑ 4 FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90 NONE ❑ 99 OTHER(Specify): 464i],_. RISER SECONDARY CONTAINMENT ❑ 1 STEEL, [34.FIBERGLASS El 10.RIGID PLASTIC ® 90-NONE ❑ 99.OTHER(Specify), 464k ._.._.........__�__._ .__. _ FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3 STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451 a-a VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION"TYPE ® I SINGLE WALL [3 2.DOUBLE WALL ❑ ,....NO DISPENSERS ❑ 90 NONE 469. _ -. _.-._..._ _____ ____ _ ..._.__._. _ _.._..__ .__.... CONSTRUCTION MATERIAL ® L STEEL ❑ 4-FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b. 469c. VIIL CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIALANODE(S) ❑ 4 IMPRESSEDCURRENT ® 6.ISOLATION 448 _ IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided3ein is true, accurate,and in full compliance with legal requirements. f' APPLICANT SIGNATURE _I DATE 3/4/2010 "° APPLICANT NAME(print) Sandy Edwards 471 APPLICANT TITLE Environmental Compliance :. UPCF UST-I3 Rev.(1212007)-1/2 www.unidocs.org ,.:.