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IN IED PROGRAM CONSOLIDATED FOP.. wspwrum UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (One form p r UST) TYPE OF ACTION (Check one item only. For a UST closure or removal, complete only this section and Sections I, II, III, IV, and IX below) 430. ❑ 1. 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: 4306. I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) 61611 ^_- I. SS N Name or DBA - Doing Business As) 3. Tesoro/Shell 68151 S 103. CITY 104, 35 N. Cherokee Lane 1 Lodi II. TANK DESCRIPTION TA,NK ID # 432. TANK MANUFACTURER 433. TANK CONFIGURATION: THIS TANK IS 434. ® 1. A STAND-ALONE TANK Complete one page for each 6�1 TruscO in ❑ 2. ONE IN A COMPARTMENTED UNIT compartment the unit. DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437, 1995 12,000 III. TANK USE AND CONTENTS TANK USE ® la. MOTOR VEHICLE FUELING ❑ lb. MARINA FUELING ❑ lc. 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: ® la. REGULAR UNLEADED ❑ lc. MIDGRADE UNLEADED ❑ 1b. PREMIUM UNLEADED 440. ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM o . (Specify): 44a _ 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 [195. UNKNOWN 443. ..........................................................................................._..........................................._.......__............. ................. _................................................................. .......... ...... -.._._................._........................................................................................I... PRIMARY CONTAINMENT ® 1. STEEL ❑ 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 ❑ 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 444a. -.._......_........_...................._....._..._.................._............. _.._._........._ _ ... ... ..... .... .... .................................._..........................................................................................................................._...........- SECONDARY CONTAINMENT ❑ I. STEEL ❑ 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER 07. JACKETED 445. ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 445a. ................................................... _...................................................................._....._......_.__._._................................ - - ----................._...............---....._._...................................._........_............................................................. OVERFILL 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 El 99. OTHER 460 .............................._.........._...........................................................................---......................................................................................._................................................................._..........................................._..._...__........................_... SYSTEM TYPE ®1. PRESSURE ❑ 2 GRAVITY El 3. CONVENTIONAL SUCTION ❑ 4 SAFE SUCTION [23 CCR §2636(a)(3)] 458. .. PRIMARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464. ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify):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 464 . VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ® 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 4644el. .............. ......-- .....--...........--.... ........... _..__._..... ---..................................._...................................................... _..... ................................................................................... _......---........_._........... .........._..................-.._............................................................................................................. .................... VENT SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ® 90. NONE ❑ 99. OTHER (Specify): 464fl ...................... ..................-----...__.__.............._.._._...__._-......_.__.............---..._.........._....................._................................................_.__..._........................................._...._................._......................----................_.__........................................................ 464g. VR PRIMARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 464gi _........................................................_........................................---..._........................ ............ ...........................__.............._............................................. _..............................................................__.................. _....._.... _._......_........----_.....__............._._........--... ................................... VR SECONDARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 464hl. ........... ..... -...._.... - -....---.....................-....._._.....---..........................................._.._................................_..........................................._............__.._.__......................_..._.__.._._.._..._...__............................................................................................................................................ - VENT PIPING TRANSITION SUMP TYPE [11. SINGLE WALL [12. DOUBLE WALL ® 90. NONE 464i' .......................................... ......................................... ....... -_..-.._..................................... _................................... _.................. _............................._....... ............. __............................. ---._.._......_._......._...--............ _._...................... __...... _............ _....................................................................... _.... ............ ................................�._.... RISER PRIMARY CONTAINMENT ® 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 464jj _.................................................................-.............__._...................................._..._........_...__..__.._............._._..._..._..---...._...._......_......__....__........._...................................................................................__._......................__.......................---.._.................._.........................__................................ 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) CONSTRUCTION TYPE ® 1 SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90 NONE 469a .................... ........_ ......................................469 ....... ......................... _.__._......._........................._...........__.................._................................................................. . _............................................................................__...._.._.........._-............._._._._... 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 providels)ttrue, accurate, and in full compliance with legal requirements. � APPLICANT SIGNATURE � 470 DATE 1/7/2011 APPLICANT NAME (print) Sandy E ards 471 APPLICANT TITLE Environmentel', - mpl & 472. 110,11r UPCF UST -B Rev. (12/2007) - 1/2 www.unidocs.org