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.. ED PROGRAM CONSOLIDATED FOi. lin UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form perAC TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11,Ill,IV,,and IX 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: 4306. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3 Shell/Tesoro 68150 BUSINESS SITE ADDRESS 103• 1 CITY 104. 13975 E. Hiway 88 Lockeford II. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 '9 / U jl ; �f` �.LTP ® I.A STAND-ALONE TANK Complete one page for each .: ❑ 2.ONE IN A COMPARTMENTED UNIT companment in the unit. DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437 1990 10,000 1 III. TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ le.AVIATION FUELING 439 El 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: 0 la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 446- CM 1 ❑ S.JET FUEL ❑ 6.AVIATION GAS _8._PETR_OLE-UMBLEND_FUEL ❑ 9.OTHER PETROLEUM(Specify): 440s_ NON-PETROLEUM:❑ 7.USED OIL - ❑ 10.ETHANOL - ❑ 11.OTHER NON-PETROLEUM(S ci •): 440b. IV. TANK CONSTRUCTION TYPE OF TANK _ _ _❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT -®-I 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 [199.OTHER(Specify): 445a. OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ® 3.FILL TUBE SHUT-OFF VALVE a52. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ I.SINGLE WALL ® 2.DOUBLE WALL ❑ Q9,OTHER 460 SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFESUCTION(23 CCR§2636(ax3)J-_- 458_ PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ l0.RIGID PLASTIC 464 ❑ 90.NONE_ ❑ 95.UNKNOWN 0_99.OTHER(Specify): 464a• SECONDARY CONTAINMENT ❑ 1 STEEL -- ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC --- 4644 ❑ 90-NONE_ ❑ 95.UNKNOWN_ ❑ 99.OTHER(Specify): 464c. PIPINGIJ'URBINE CONTAINMENT SUMP TYPE N 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 ❑ l0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(S cifv): 464e VENT SECONDARY CONTAINMENT-[I I.STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE [199.OTHER(Specify): 464n. VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464 VR SECONDARY CONTAINMENT [11.STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL _® 90.NONE 464' RISER PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): _ 464J a64L_. RISER SECONDARY CONTAINMENT ❑ 1.STEEL El 4.FIBERGLASS [IIT RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464k), FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATFJBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45tac VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a. ----------------- ---' -- ----------------_._.-- ---------------------------.._---.._..469b CONSTRUCTION MATERIAL ® L STEEL ❑ 4.FIBERGLASS ❑ W.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: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate,and in full compliance with legal requirements. APPLICANT SIGNATURE DATE 4/28/2011 470 APPLICANT NAME(print) Sandy E wards 471' APPLICANT TITLE Environmental Compliance 472 UPCF UST-B Rev.(1212007)-112 www.unidocs org