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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION — TANK INFORMATION (One form per USI) T1 -PI ( it v 1 I( )N (Check one item onb For a UST closure or removal. complete onh- /his section and Sections 1, /l, lll. IV and tvbelou) 430 ❑ I N1_W PERMII ❑ 3. RENEWAL. PERMIT ® 5 CHANGE OF INFORMAII(1N ❑ 6. TEMPORARY UST CLOSURE: ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL DA IT LIST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED 41Ob I. FACILITY INFORMATION FACILITY ID #1 (Agency ( se Only) _ __ ('>FZ BUSINESS NAME (Same as Factlig iame or DBA - Doing Business ;Is) Tesoro/Shell 68151 BUSINESS SITE ADDRESS 101 CITY 07 35 N. Cherokee Lane 1 Lodi II. TANK DESCRIPTION ANE: ID k (% 432 /b TANK MANUFACTURER 4:3 TANK CONFIGURATION: THIS TANK IS 434 ® 1 A STAND-ALONE TANK Cnmpiele one page for each - �e 7 TI'L1SC0 in ❑ 2 ONE INA COMPARTMENTED UNIT camriw, t th, unit DATE UST SYSTEM INSTALLED 4J5 TANK CAPACITY IN GALLONS ¢36 NUMBER OF COMPARTMENTS IN THF UNIT 4'7 1995 10,000 III. TANK USE AND CONTENTS TANK USE ® la MOTOR VEHICLE FUELING ❑ Ib. MARINA FUELING ❑ lc AVIATION FUFL INO 439 ❑ + CHEMICAL PRODUCT STORAGE ❑ 4 HAZARDOUS WASTE (Includes Used oil) ❑ 5 EMERGENCY GENERATOR FUF1. (Ilse 4252815(o) ❑ b OTHER GENERATOR FUEL ❑ 95 UNKNOWN HER ci ) 430. CONTENTS PETROLEUM ❑ ta. REGULAR UNLEADED ❑ Ic MIIX7RADE UNLEADED Ih PREMIUM UNLEADEI 440 ❑ 3. DIESEL ❑ 5 JET FUEL t, A. ' IATI SAS ❑ 8PETROLEUM BLEND FUEL, ❑ 9 OTHER PETROLEUM (Speclth 440a NON -PETROLEUM ❑ 7 USED 0I1. ❑ 10 ETHANOL. ❑ 11 OTHER NON-PETROLEUM(S if ): 440b IV. TANK CONSTRUCTION TYPE{ OF TANK ❑ 1 SINGLE WALL ® 2 DOUBLE, WALL ❑ 95 I;NKNOWN 447 _ PRIMARY CONTAINMENT ® I STEEL ❑ 3 FIBFR(A.ASS ❑ 6 INIERNAL BLADDER 444 ❑ '. STEEL + INTERNAL LINING ❑ 95 UNKNOWN ❑ 99. OTHER (Sprat) ). 444a SECONDARY CONI AINMENT ❑ L STEEL ❑ 3. FIBIiRGLASS ❑ 6 EXTERIOR MEMBRANE LINER ® 7 JACKETED 445 ❑ 90 NONE ❑ 95. UNKNOWN ❑ 99 OTHER (Specify) 445a OVERFII.I. PREVEN'T'ION ❑ 1 AUDIBLE & VISUAL ALARMS ❑ 2 BALL I I OAT ® 3 FILL TUBE SHUT-OFF VALVE; 010 4 TANK MEET'S REQUIREMENTS FOR EXEMPTI(,)N FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT / WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ L SINGLE WALL ® 2 DOUBLE WALL C] U9 OTHER 4( SYSTEM TYPE. ® I. PRESSURE ❑ 2. GRAVITY ❑ 1 CONVENTIONAL SUCTION ❑ 4 SAFE SUCTION (2) CCR 42630.0)1 458 PRIMARY CONTAINMFNT ❑ 1 STEEL ® 4 FIBERGLASS ❑ 8 1 I -I NH3LF ❑ W RIGID PLASTIC A64 ; ❑ 90 NONE ❑ 95 UNKNOWN ❑ 99 OIHL:R (Specifi). 464a 4606 SECONDARY CONTAINMENT ❑ 1 STEEI. ®4 FIBFRG[ ASS ❑ 8 FLEXIHI E ❑ 10 RIGID PLASTIC ❑ 90 NONE ❑ 95 UNKNOWN ❑ 99 Ofi1FR Slkcity) 4fAc PIPING/TURBINE CONTAINMENT SUMP TYPE ® 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90 NONE. 4a4d 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) VAc ii VENT SECONDARY CONTAINMENT ❑ 1 stiff ❑ 4 FIHEROLASS ❑ 10 RIGIDPI ASTK ® 90 NONE ❑ 99 OTHER(Specify) 464E 464f1 —. VR PRIMARY CONTAINMENT ❑ 1 STEEL ® 4 1 11WRGLASS ❑ 10 RIGID PLASTIC ❑ 90 NOM: ❑ 99 OTHER (Spc6R) 4 464g4681 VR SECONDARY CONTAINMENT ❑ 1 STEEL ® 4 1"iBERGLASS ❑ 10 RIGID PLASTIC ❑ 90 NONE ❑ 99 OTHER (Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ 1 SINGLE WAI 1. ❑ 2 DOUBLE WALL ® 90 NONE 464, RISER PRIMARY CONTAINMENT ® 1 STEEL ❑ 4 F1131 RGI ASS ❑ 10 RIGID PLASTIC ❑ 90 NONE ❑ 99 OTHER (Slxcify) _ _ 464 1 RISER SECONDARY CONTAINMENT ❑ I 5111 1, ❑ 4 F113FROI ASS ❑ 10 RIGID PLASTIC ® 90 NONE ❑ 99 OTHER (Specify)464kI 1`111 COMPONENTS INSTALLED ® 1. SPILL BUCKF 1 ® 3. STRIKER PLATE/BOTTOM PROTECTOR ❑ 4 CONTAINMENT SUMP 451a"` VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ®1. SINGLE: WALL, ❑ 2 DOUBLE WALT_ ❑ 3 NO DISPENSERS ❑ 90 NONE Z93 CONSTRUCTION MATERIAL ® 1- STEEL ❑ 4 FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 99 OTHER (Specify) 409 VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODF(S) ❑ 4. IMPRESSED CURRENT ® 6 ISOLATION 448 IX. APPLICANT SIGNATURE CFRTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information prc#4 is true. _ accurate and in full cotaliance with 1 al requirements. .LL a7 -n (CANT SIGNATURE DATE 8/26/2011 APPLICAN I NAME (print) Sandy E wards ''' 41, APPLICANT TITLE Environmenta . 'ol1ance t`"PCF l S7' -B Rei. (IZ/2i107) - I/2 www.uaidocs.org �'