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OC <br /> UNIFIED PROGRAM CONSOLIDATED FORM 1.4'Z <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) <br /> TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,11,III,IV,and IX below) 430 <br /> ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ® 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSEIQ: 430. 1 DATE EXISTING UST DISCOVERED: 430b <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 <br /> Pacific Bell Telephone Company dba AT&T Califomia UE020 <br /> BUSINESS SITE ADDRESS 103 1 CITY 104 <br /> 124 West Elm Street Lodi <br /> H.TANK DESCRIPTION <br /> TANK ID# A32 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 <br /> UE0200001 MODERN WLD ®1.A STAND-ALONE TANK <br /> ❑2.ONE IN A COMPARTMENTED UNIT. <br /> Mal <br /> Complete out a for each com artment in the unit. <br /> DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 <br /> 2001 8000 1 <br /> III.TANK USE AND CONTENTS <br /> TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439 <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(luciudes Used Oil) ® 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a <br /> CONTENTS PETROLEUM:. ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ ib.PREMIUM UNLEADED 44U <br /> N 3.DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440% <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUM(Spec' ): 440b <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL E3 95.UNKNOWN 443 <br /> PRIMARY CONTAINMENT ® L STEEL ❑ 3.FIBERGLASS C3 6.INTERNAL BLADDER 444 <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a <br /> SECONDARY CONTAINMENT ❑ ].STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445. <br /> OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS L3 2.BALL FLOAT CM 3.FILL TUBE SHUT-OFF VALVE 452. <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑1.SINGLE WALLED ®2.DOUBLE-WALLED ❑99.OTHER 460 <br /> SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY ® 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(a)(3)l 458 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ® 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a <br /> SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ® 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464� <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE 8, 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 464d <br /> VL VENT,VAPOR RECOVERY(VR)AND RISER/FII.I.PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT 0 1.STEEL jg 4.FIBERGLASS C3 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464e <br /> 464el <br /> VENT SECONDARY CONTAINMENT L STEEL 4.FIBERGLASS 10.RIGID PLASTIC 19 90.NONE 99.OTHER(Specify) 464f <br /> 464fl <br /> VR PRIMARY CONTAINMENT L STEEL 4.FIBERGLASS 10.RIGID PLASTIC j@ 90.NONE 0 99.OTHER(Specify) 464g <br /> 464el <br /> VR SECONDARY CONTAINMENT L STEEL 4.FIBERGLASS 10.RIGID PLASTIC 1@ 90.NONE 0 99.OTHER(Specify) 4641+ <br /> 464b1 <br /> VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 0 90.NONE 4641 <br /> RISER PRIMARY CONTAINMENT IN L STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC 13 90.NONE 0 99.OTHER(Specify) 4641 <br /> 464'I <br /> RISER SECONDARY CONTAINMENT 0 L STEEL 10 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464k <br /> 464k1 <br /> FILL COMPONENTS INSTALLED 13 1.SPILL BUCKET 0 3.STRIKER PLATE/BOTTOM PROTECTOR Cg 4.CONTAINMENT SUMP 451ac <br /> VII.UNDER DISPENSER CONTAINMENT(UDC} <br /> CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 3.NO DISPENSERS ❑ 90.NONE 469& <br /> CONSTRUCTION MATERIAL ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b-c <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ® 6.ISOLATION 448• <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, <br /> and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 470, <br /> 6/9/2009 <br /> APPLICANT NAME(print) 471' APPLICANT TITLE ala <br /> Steven J Hall Manager, EH&S <br /> UPCF UST-B-1/1 Rev.(12/20071 <br />