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ED PROGRAM CONSOLIDATED FOR I/IMPUx NDERGROUND STORAGE TANK(tee 2M5' OPERATING PERMIT APPLICATION - TANK INFORMATION T) TYPE OF ACTION (Check one item only, For a UST closure or removal, complete only this section and Sections 1, 11, 111. IV. and IX below) 430. ❑ I. NEW PERMIT ❑ 3. RENEWAL PERMIT ® 5. CHANGE OF INFORMATION El 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 430& 1 DATE EXISTING UST DISCOVERED: 43% I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) _ 1. aciliq Name or DBA - Doing Business As) 3 Tesoro/Shell 6815 KESS 103- CITY Ia. 35 N. Cherokee Lane I Lodi II. TANK DESCRIPTION TANK ID # 432. TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434, 1 G IA- 0 50 55 �`'I Trusc0 ® 1. A STAND-ALONE TANK Complete one page fa euh 2, ONE IN A COMPARTMENTED UNIT cumpanmem in the unit, DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437 1995 10,000 M. TANK USE AND CONTENTS TANK USE ® la. MOTOR VEHICLE FUELING ❑ Ib. MARINA FUELING ❑ Ic. AVIATION FUELING 439. ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 5. EMERGENCY GENERATOR FUEL [HSC §25291.5(c)] ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439& CONTENTS PETROLEUM: ❑ la. REGULAR UNLEADED ® lc. MIDGRADE UNLEADED ❑ Ib, PREMIUM UNLEADED 440. ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (Specify): 4408. NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ❑ 11. OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ L SINGLE WALL ® 2. DOUBLE WALL ❑ 95. UNKNOWN 44 INTEL BLADDER 444. PRIMARY CONTAINMENT ®i. STEEL ❑ 3 FIBERGLASS 136. RNA ❑ 7. STEEL+ INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 4448. SECONDARY CONTAINMENT ❑ I. STEEL ❑ 3, FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ® 7. JACKETED 845. NONE 0 95_ UNKNOWN 0 99. OTHER (Specify): 445a. _.-.._0-90. . - - OVERFILL PREVENTION ❑ I. AUDIBLE & VISUAL ALARMS [32. 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 ❑ I. SINGLE WALL ® 2. DOUBLE WALL ❑ ".OTHER 460 SYSTEM TYPE ® I. PRESSURE ❑ 2. GRAVITY 459 O 3. CONVENTIONAL_ SUCTION 4�SAFE SUCTION �z3 CCR §8636(8._x3)] _ _ PRIMARY CONTAINMENT ❑ 1. STEEL 0 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464. ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464& SECONDARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 95. UNKNOWN - ❑ 99. OTHER (Specify)_ 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ® I. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90, NONE 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):464e. VENT SECONDARY CONTAINMENT ❑ I. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ® 90. NONE ❑ 99. OTHER (Specify): 464f. VR PRIMARY CONTAINMENT ❑ I. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 4646. 464&1. VR SECONDARY CONTAINMENT ❑ I. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 46444 1. VENT PIPING TRANSITION SUMP TYPE ❑ 1. SINGLE WALL ❑ 2. DOUBLE WALL ® 90. NONE 464i RISER PRIMARY CONTAINMENT ® L STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): gy�ij RISER SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ® 90. NONE ❑ 99.OTHER (Specify): 464k. 464k1..._ ..__._ ._ _ _..._. _.._. __.__ __...----_.---- FILL COMPONENTS INSTALLED ® 1. SPILL BUCKET ® 3. STRIKER PLATEIBOTTOM PROTECTOR ❑ 4. CONTAINMENT SUMP 454--c VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE® L SINGLE WALL ❑ 2 DOUBLE WA ...... CONSTRUCTION MATERIAL ® L STEEL ❑ 4 FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99, OTHER (Specify) 4699b. 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 provided herein is true, accurate, and in full compliance with legal requirements. APPLICANT SIGNATURE DATE 1/20/2011 470 APPLICANT NAME (print) Sandy 4vards 471 APPLICANT TITLE Environmental Compliance 472 UPCF UST -B Rev. (12/2007) - 1/2 www.unidocs.org