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UNIFIED PROGRAM CONSOLIDATED FORM
<br />UNDERGROUND STORAGE TANK
<br />OPERATING PERMIT APPLICATION -TANK INFORMATION (One f'orniPer UST)
<br />TYPE OF ACTION (Check one item only. For a UST closure or removal, complete onlY this section acrd Sections 1, 14 ill, /V, and ffbelolv)
<br />430
<br />El 1. NEW PERMIT 0 3. RENEWAL PERMIT 0 5, CHANGE OF INFORMATION
<br />[] 6, TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ONSITE 0 S. LIST REMOVAL
<br />DATE UST PERMANENTLY CLOSED: 4301 1 DATE EXISTING LIST DISCOVERED
<br />4,;Ob
<br />I. FACILITY INFORMATION
<br />LAGILITY 11) Iwncj- (J'se Only)
<br />BU ISINE'.SS NAME (Same as racilitY.Vaine or DRII - Doing Business As)
<br />USA/Tesoro 68151
<br />BUSINESS SITE ADDRESS
<br />CITY
<br />14
<br />35 N. Cherokee Lane
<br />1.,odi
<br />11. TANK DESCRIPTION
<br />TANK ID 4 412 TANK MANUFACTURER
<br />TANK CONFIGURATION: THIS TANK IS
<br />4,14
<br />2 Trusco
<br />0E A STAND-ALONE TANK co.plete page for -h
<br />[1 2, ONE IN A COMPARTMENTED UNIT -w-a-t i,, the
<br />DATE UST SYSTEM INSTALLED s3sLANK CAPACITY IN GALLONS 4T6
<br />NUMBER OF COMPARTMENTS IN THE UNIT
<br />1995 10,000
<br />111. TANK USE AND CONTENTS
<br />LANKUSE 0 1a,NIOTOR VEHICLE FUELING ❑ I b. MARINA FUELING C1 la AVIA'I ION rUELING
<br />t
<br />0 3 CHEMICAL PRODUCT STORAGE El 4, 1 1AZARDOUS , WASTE u,cj cio ❑ 5 EMEPGENCY GENERATOR FUEL (HSC §25231
<br />5('11
<br />0 6. OTHER GENERATOR FUEL ❑ 95, UNKNOWN ❑ 99, OTHER (Spccifv):
<br />439a
<br />CONTENTS PETROLEUM: C3 Ia. REGULARUNLFADI-D k.MIDGRADEt ' INLEADED ❑ Ib. PREMIUM UNLEADED
<br />as
<br />[] 3, DIESEL L 0 5, JET FIJT0 6, AVIATION GAS
<br />El 8, PETROLEUM BE FUEL C1 9.OTHER PETROLEUM (Spwfy). 140a
<br />NON -PETROLEUM E] -7 USED OIL C] - 10 "1 ET -HANOI.
<br />El I I. o,rHER NON -PETROLEUM (Specify). 440b
<br />IV. TANK CONSTRUCTION
<br />TYPE OF TANK ❑ SING[ Ic WALL ®Z UC7UEll.E WAt L ❑ 95 CJNKN0IVN
<br />441
<br />� PRIMARY COYT.AINMEN`h ® t STEEL ❑ 3. F`IGERCiLASS ❑ 6 IN'T'ERNAL GLADDER
<br />444
<br />C] STEEL INTERNAL LINING 0 95. UNKNOWN 0 99. OTHER (Specify) 444,,
<br />SECONDARY CONTAINMENT g I STEEL ❑ 3 FIBERGLASS , 6. EXTERIOR - IMEMBRANE LINER E3 7, JACKETE-.D
<br />445
<br />90. NONE 95. UNKNOWN 0 99, OTHER (SpecifN)
<br />0...
<br />. ......
<br />.
<br />OVERFILL, PREVENTION ❑ I AUDIBLE &VISUAL ALARMS ❑ 2. BALL FLOAT 3. FILLTUBESHUT-OFF VALVE.
<br />452
<br />C3 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION �F(UIPMI��NT_
<br />V. PRODUCT / WASTE PIPING CONSTRUCTION
<br />PIPING CONSTRUCTION 0 1, SINGLE WALL 0 2, DOUBLE WALL El 99, OTHER
<br />460
<br />1. PRESSURE 0 2, GRAVITY [3 .3. CONVENTIONAL SUCMON F1 4.SAFE,SU�jION[2.1CCR§2
<br />458
<br />ij, .... .... ..❑..... . .... ------
<br />Pkjl,fA�k CONTAINNIE NT 1. STEEL 0 4 FIBERGLASS [3 8 FLEXIBLE 0 10 RIGIDPLA-STIC
<br />464
<br />[1 90 NONE 0 95, UNKNOWN [1 99. OTHER (Specify) 464a
<br />SECONDARY CONTAINMENT 0 t STEEL ®4 FIBERGLASS ❑ 8 FLEXIBLE ❑ 10 RIGIDPLASTIC
<br />[1 90, NONE 0 95UNKNOWN [1 99. OTHER (Specify): 4648
<br />PL0I_Nd1UkIhNt CONTAINMENT SUMP TYPE 0 1 SINGLE WALL [1 2. DOUBLE WALL C3 90, NONE
<br />464d
<br />VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION
<br />VENT PRIMARY CONTAINMENT 0 1 STEEL E] 4 FIBERGLASS 0 10 RIGIDPLASr[C C]90_ NONE 0 99 OTHER (Specify};
<br />4464e
<br />640)
<br />VENT SECONDARY CONTAINMENT [I I STEEL 0 4. FIBERGLASS ❑ 10, RIGID PLASTIC 0 90 NONE 0 99,OTHER (Specify)
<br />4 464f
<br />VR PRIMARY CONTAINMENT [I LSTEEL N 4, FIBERGLASS El 10, RIGID PLASTIC ❑El 90� NONE ❑[1 99, OTHER (Specily):
<br />464S
<br />�02L_
<br />VR SECONDARY CONTAINMENT 0 1, STEEL 0 4 FIBE'ROLASS 10, RIGID PLASFIC 0 90 NONE ❑0 99 OTHER (,SP,6vV):
<br />464h
<br />4(,4hi
<br />........ .. - -----
<br />VENT PIPING TRANSITION SUMP TYPE 0 LSINGLE WALL ❑ 2. DOUBLE WALL 90, NONE
<br />444i
<br />...... . ....
<br />RISER PRIMARY CONTAINMENT 0 L SITE[, ❑0 4, FIBERGLASS ❑0 10 RIGID PLASTIC [1 90, NONE ❑0 99, OTI IE I R (Specify) --- ----
<br />4644j64j
<br />---- ---
<br />RISER SECONDARY CONTAINMENT [I LSTEEL 0 4.FIBERGLASS ❑ 10 RIGIDPLAsHc 90 -NONE ❑ 99. OTHER (Specify):
<br />464k
<br />464k I
<br />...... . . . ............ . .......... .. ...... ... - . . .... ............ . -- ---- - -
<br />FILL COMPONENTS tNI. SPILL BUCKET .1. STRIKER PLATEiBO`I7OM PROTECTOR 0 4. CONTAINMENT SUMP
<br />451 -
<br />VII. UNDER DISPENSER CONTAINMENT (UDC)
<br />CONSTRUCTION TYPE 1, SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE
<br />469a
<br />CONSTRUCTION MATERIAL, 1. STEEL 0 4. FIBERGLASS ❑ 10, RIGID PLASTIC 0 99.0-1-11ER (Specify)
<br />469b
<br />46140
<br />VIII. CORROSION PROTECTION
<br />STEEL, COMPONENT PROTECTION 0 2. SACRIFICIAL ANODES) 11 4, IMPRESSED CURRENT 6. ISOLATION
<br />448
<br />IX APPLICANT SIGNATURE
<br />CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,
<br />accurate and in full compliance with leg!l requirements.
<br />APPLICANT SIGNATUREDATE 2/8/2010
<br />470
<br />APPLICANT NAME 11print) Sandy EdNk--ards
<br />471 APPLICANT TITLE Environmental Compliance
<br />472
<br />I WF UST -0 Rev. (1212007) - 1/2 www.unidoes.org
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