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C, Fes` UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION —TANK INFORMATION (One form per UST) TYPE OF A(' 1 ION (Check one item only. For a (LST closure or removal. complete ,wh• this section and .Sections I, l/. /ll, 11 and l.Y helou l 430 ❑ 1 N1 V1 PI RbILI ❑ ? RE=NEWAL PERMIT ® 5. CHANGE UI: INFORMATION n. 1 LNIPOR:IRY UST CLOSURE ❑ 7 UST PERMANENT CLOSVRL- ON SITE ❑ & UST REMOVAL_ _❑ DATE LIST PERMANENTLY CLOSED: 430a DATE F,XISTING UST DISCOVERED 4301, I. FACILITY INFORMATION 2 ! —T ) {=AGILITY ED q (Agency Use Only) 7 O BUSINESS NAME: (Same as Facilitr;Vame or DBA Doing Business As) : Tesoro/Shell 68151 BUSINESS SITE ADDRESS 10) CITY 104 35 N. Cherokee Lane Lodi II. TANK DESCRIPTION I) _ 43' TANK 11)!A TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 444 �\ J� I TrtISCo ® 1 A STAND-ALONE TANK Complete otte page rw each ❑ 2 ONE IN A COMPARTMENTED UNIT companment in the unit DATI I IST SYSTFM INSTALLED 4�5 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 427 1995 10,000 III. TANK USE AND CONTENTS TANK IISE ® la. MOTOR VEHICLE FUELING ❑ Ib MARINA FUELING ❑ Ic AVIATION FUELING 4:9 ❑ 3 CHEMICAL PRODUCT STORAGE ❑ 4 HAZARDOUS WASTE dncludcs Uwd Oil) ❑ 5 EMERGENCY GENERATOR FUEL IHSS F25; i >ic)j ❑ 6 OTHER GENERATOR FUEL. ❑ 95 UNKNOWN ❑ qq OTHER (Specify) 41% CONTENTS PETROLEUM: UNLEADED ❑ Ic MIDGRADE UNLEADED ❑ It, PREMIUM UNLEADED 440 �AR 3 DIESEL ❑ 5 JET FUEL. ❑ 6 AVIATION GAS 8. PE ROLEUM BLEND FUEL ❑ 9 OTHER PETROLEUM ISpectty). 440. NON -PETROLEUM:❑ 7 USED OIL ❑ EO ETHANOL ❑ I I OTHER NON -PETROLEUM (Specify). 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ I SINGLF WALL ® 2 DOUBLE WALL ❑ 95 UNKNOWN 443 PRIMARY CON'TAINMEN ® I sli l l ❑ 3 FIBERGLASS ❑ 6 INTERNAL. BLADDER 444 ❑ '. S7f.L1. - INTLRNAI LINING ❑ 95. UNKNOWN ❑ 99 OTHER(SPccify) 444a SECONDARY CONTAINMENT ❑ 1 STEEL ❑ 3 FIBERGLASS ❑ 6 EXTERIOR MEMBRANE LINER ® 7. JACKETED 445 ❑ 90 NONE ❑ 95. UNKNOWN ❑ 99 OTHER (Specify) 445a OVERFILL, PREVENTION ❑ 1 AUDIBLE & VISUAL ALARMS ❑ 2 BALL FLOAT ® 3. FILL TUBE SHUT" -011 VALVE 452 4. TANK MEETS REQUIREMENTS FOR EXI. MPTION FROM OVERFILL PREVENTION E UIPMEN I V. PRODUCT / WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1 SINGLE. WALL ® 2. DOUBI.EI WALT. ❑ (i) OTHER 460 _ - SYSTEMTYPE ® 1 PRESSURE ❑ 2 -GRAVITY ❑ 1 CONVENIIONALSUCTION ❑ 4 SAFE SLiCTION12.1 CCR ¢X361ax3)] 458 PRIMARY CONTAINMENT ❑ I STEEL ® 4 FIBFiRC1LASS ❑ 9 1 LEXIBI li ❑ 10 RILED PIAS"I IC 464 ❑ 90 NONE ❑ 95 UNKNOWN ❑ 99 OTHER (Specify) 464s SECONDARY CONTAINMENT ❑ I STEEL ® 4 FIBERGLASS ❑ 8 FLEXIBLE. ❑ 10 RIGID PLASTIC 4646 ❑ 90 NONE ❑ 95 UNKNOWN ❑ 99 OTHER(Specify) 464, PIPINUITURBINE CONTAINMENT SUMP TYPE ® I SINGLE WALL ❑ 2 RUBLE WALI ❑ 90 NONE 464d VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ® 1 STEEL 4 FIBERGLASS ❑ 10 RIGID PLASTIC [190 NONE ❑ 99 OTI{F.R ISpecifcr 4l .464f VENT SECONDARY CONTAINMENT ❑ 1 S ILLL ❑ 4 FIBERGLASS ❑ 10 RIGID PLASTIC ® 90 NONE ❑ 99 OTHER (Specify) 464f) VR PRIMARY CONTAINMENT ElI STEEL ❑ 4 FIBERGLASS [110. RIGID PLASTIC ® 90 NONE [1 91) OTHER (Speaf> ) 4464Mi VR SECONDARY CONT.AINMI N"l E31 SHI-,1 ® 4 FIBERGLASS ❑ 10 RIGID PLASTIC [190 NONE ❑ 99 OTHER (Spccd.I 464h 464h1 VENT PIPING TRANSITION SI)MP TYPE ❑ I SINGLE WALL ❑ 2 DOUBLF WALL_ ® 90. NONE 464' 464 _. RISER PRIMARY CONTAINMFNT ® I STEEL ❑ 4_ FIBERGLASS E3to RIGID PI ASTIC [390, NONE? ❑ 99 OTHER (Spea4_.f.) I _ ._ 1. _.... _..... ..__. __.... . .. ...... .. RISER SECONDARY CONTAINMENT ❑ 1 STEEL 4 FIBERGLASS [D19 RIGID PLASTIC ® 90 NONE. ❑ 99. OTHER (Spectty ) 4641. a6ak l FILL COMPONENTS INSTALLED ® 1 SPILL BUCKET ® 3. STRIKER Ill A IL'13011 OM PROTECTOR ❑ 4 CONTAINMENT SUMP 451e -c VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® 1 SINGLF WALL ❑ 2 DOUBLE WALL ❑ 3 NO DISPENSERS ❑ 90 NONE 4ti9a _ ._ CONSTRUCTION MATERIAL ® 1. STEEL 4 FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 99 OTHER (Specify) 4696 469c VIII. CORROSION PROTECTION STEEL. COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODES) ❑ 4 IMPRESSED CURRENT ® 6 ISOLATION 448 IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this IIST system is compatible with the hazardous substance stored and that the information provided herein is liue. accurate nd in full compliance with legal requirements. _ ti _ APPIICAN'T SIC;NATl1RE I)AT( 8/26/2011 APPI IC'ANT NAME (print Sandy Ed ards 4" APPLICAN] TTiI+ Environmental Compli – -- UPCF UST -8 Rev. 02/2007) - 1/2 www.unidocs.org