|
•
<br />0
<br />UNIFIED PROGRAM CONSOLIDATED FORM
<br />UNDERGROUND STORAGE TAMC
<br />OPERATING PERMIT APPLICATION -TANK INFORMATION (One form per UST)
<br />TYPE OF ACTION (Check one stern oniv. b -or a USTclosure or removal, complete onjy this section andSections 1. 11, 111, 11' and LV belolv)
<br />430
<br />0 1, NEW PERMIT El 3, RENEWAL PERMIT 0 5. CHANGE OF INFORMATION
<br />PERMANENT CLOSURE ON SITE [] 8. UST REMOVAL
<br />• DATE [jSTPFRMANEN ITY CLOSED: 4aoa i DATE EXISTING UST DISCOVERED:
<br />1306
<br />I. FACILITY INFORMATION
<br />FACILITY ID # (Ageno- Use OnIO
<br />BUSINESS NAME (.SameasP(iciliti,,,VaineorDBII Doing HusinessAsj
<br />USA/Tesoro 68151
<br />BUSINESS SITE ADDRESS 103
<br />CITY
<br />104
<br />5 N. Cherokee Lane
<br />Lodi
<br />U. TANK DESCRIPTION
<br />TANK ID # 43' 'TANK MANUFACTURER 433 j TANK CONFIGURATION: THIS TANK IS
<br />434
<br />9 1, A STAND-ALONE TANK Complete ore page
<br />Trusco
<br />far each
<br />2 ONE IN A COMPARTMENTED UNIT mRWt in the
<br />unit
<br />DATE UST SYS FEM INSTALLED TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT
<br />43
<br />1995 12,000
<br />111. TANK USE AND CONTENTS
<br />-TANK USE 0 la..MOTOR VEHICLE, FUFLING [I lb. MARINA FUELING 0 lc. AVIATION FUELING
<br />439
<br />0 1 CHEMICAL PRODUCT STORAGE 0 4. HAZARDOUS WASTE tlixl,a&a u i oil) 0 -1 F_-MERGENCY GENERA fOR FUEL ff[SC §2iM
<br />+(c)j
<br />0 6, Of HER GENERATOR FUEL 0 95, UNKNOWN 0 99 OT14ER (Specify):
<br />431)a
<br />LE1 I A 1 1: 0 1.� R I E , GULA R UNLEADED 0 Ic MIDGRAD E UNLEADED - 0 lb PREMIUM t , ;NLEADED
<br />CONTENTS PETROLEU
<br />440
<br />0 1. DIESEL 0 5 JET FUEL 0 6. AVIATION GAS
<br />0 8 PETROLEUM BLEND FUEL 0 9 OTHER PETROLEUM (Specif,), 440a
<br />ONPE [!! 14 ETHANOL
<br />N T
<br />0 11, OTHER NON -PETROLEUM (Specifv): 440b
<br />IV. TANK CONSTRUCTION
<br />TYPT'. OI TANK 0 1 SINGLEWALL 0 1DOLMLEWALL. 0 95. UNKNOWN
<br />443
<br />krVIARY, CONTAINMENT E3 I -, S f E E E, - - , , , , -0, -3 - F 16 E, R G, L-A- S_ S 0- 6-,. 1' N_T E R-N- A L BLADDER .-11-44a
<br />1
<br />0 1. STEEL - INTERNAL LINING 0 95. UNKNOWN 0 99.OrHER(Specify)� 444.
<br />........ . .... ... _-- _----
<br />S,Ec6Nf),kkyic6N_,IAINMENr 0 1. STEEL. 0 3. FIBERGLASS 0 6, EXTERIOR MEMBRANE LINER 7 JACKETED
<br />44'
<br />0 90. NONE 0 95, UNKNOWN 0 99 OTHER (Specify), 445a
<br />6vFki�iCil 1. AUDIBLE & VISUAL ALARMS 0 2. BALI, FLOAT I, FILL TUBE SHUT-OFF VALVE
<br />0 4 TANK MEETS PFQUIRFMENTS FOR EXEMPTION FROM OVERFILL, PREVENTION EQI,flPMFN,r
<br />V. PRODUCT / WASTE PIPING CONSTRUCTION
<br />PIPING CONSTRUCTION 0 1 SINGLE'. WALL 2 DOUBLE WALL 0 91), OTHER
<br />4w
<br />SYSTEM TYPE ZLPRESSURE 0 2, 6RAVfTY 0 3. CONVENTIONAL, SUC I [ON 0 4 SAFE SU TCTJON 123 CCR
<br />4;3
<br />PRIMARY CON TAINIVIENT I STEEL Ej I FIBERGLASS 0 8 FLEXIBLE 0 16- RIGID PLASTIC
<br />4 64
<br />0 90. NONE 0 95. UNKNOWN, 0 9,9� OTL MR Specify) 4(Aa
<br />I - STEEL -4, FIBERGLASS 0- 8,' FLEXLB'LE 0 10, RIGID PLASTIC
<br />4 , 6 4 , b -
<br />0 90. NONE 0 95. UNKNOWN 0 99. OTHER (Specify)_: 464c
<br />PiLi'IN6,,16k IN ----CONTAINMENT SUMP TYPE— 1, SINGLE WALL El 2. DOUBLE WALL 0 90. NONE
<br />4& ad
<br />VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION
<br />VENT PRIMARY CONTAINMENT 0 LSTEEL 0 4 FIBERGLASS 0 10, RIGID PLASTIC 0 90 NONE 0 99 OTHER (Specif�y)-
<br />464t
<br />464'e!
<br />VEN r SECONDARY CONTAINMENT 0 1 STEEL 0 4. FIBERGLASS 0 10 RIGID PLASTIC 0 90. NONE 0 9q OTHER (Specify):
<br />46446 4flf,
<br />VR PRIMARY CONTAINMENT 0 1 STEEL 0 4 FIBERGLASS 0 10, RIGID PLAS HC 0 90. NONE 0 99. OTHER (Specifv):
<br />64g
<br />4<
<br />VR SECONDARY CONTAINMENT [3i STEEL 0 4, FIBERGLASS 0 10, RIGID PLASTIC 0 90, NONE 0 99. OTHER (Specify):
<br />4h
<br />46a216hi
<br />VENT PIPING TRANSITION SUMP TYPE 0 LSINGLE WALL 0 2 DOUBLE WALL. 0 90, NONE
<br />4(Ai
<br />RISER PRIMARY CONTAINMENT 0 LSTEEL C1 4. FIBERGLASS 0 10, RIGID PLASTIC 0 90, NONE 0 99, OTHER (Specify):
<br />464j
<br />RISER SECONDARY CONTAINMENT C] I STEEL 0 4 FIBERGLASS 0 10, RIGID PLASTIC 0 90. NONE C] 99. OTHER (Sfyxi(v);
<br />4 464k
<br />FILL COMi'ONENTS INSTALLED ® I. 'SPILL. ,-B-U"(-.Kl.-,*'F- 3. "STRIKER ,-,P-,L,A,l-*,-E,-i3,O'*-rl'O M --PROTECTOR,------ _ 4. CONTAINMENT SUMP
<br />451a,c
<br />VII UNDER DISPENSER CONTAINMENT (UDC)
<br />CONSTRUCTION TYPE 1. SINGLE WALL ❑ 2. DOUBLE WALL 0 3, NO DISPENSERS 0 90, NONE
<br />460a
<br />CONSTRUCTION MATERIAL 1 STEEL 0 4. FIBERGLASS 0 I0,RIGID PLAS1IC' 0 99 OTHER (Specify)
<br />46 b
<br />409c
<br />VIII. CORROSION PROTECTION
<br />STEEL COMPONENT PROTECTION [I 2. SACRIFICIAL ANODE(S) [1 4, IMPRESSED CURRENT 6. ISOLATION
<br />448,
<br />IX. APPLICANT SIGNATURE
<br />CERTIFICATIQN: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is
<br />true,
<br />accurate, and in full compliance with legal requirements.
<br />APPLICANT SIGNATURE DATE 2/8/2010
<br />470
<br />APPLICANT NAME (print) Sandy Ed aids 471 APPLICANT TITLE Environmental Compliance
<br />412
<br />UPCF UST -B Rev. (12/2007) - 1/2 www.unidoes.org
<br />
|