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UNIFIED PROGRAM CONSOLIDATED FORM
<br />UNDERGROUND STORAGE TANK
<br />OPERATING PERMIT APPLICATION —TANK INFORMATION (One form per UST)
<br />TYPE OF ACTION (Check orle aemonly, For a UST closure or removal, complete only_ this section andSection 1. 11. /H. lf. and byhelow)
<br />41,1
<br />Ej 1, NEW PERMIT 3. RENEWAL PERMIT ED 5, CHANGE OF INFORMATION
<br />D 61TEMPORARY UST CLOSURE ❑ 7. u,,sT PERMANENT CLOSURE ON SITE 0 8. UST REMOVAL
<br />DATE UST PERMANENTLY CLOSED: 131a I DATE EXISTING UST DISCOVERED:
<br />I
<br />Nola
<br />I. FACILITY INFORMATION
<br />FACILITY 11) # (Jgency Use Onl,W
<br />t.
<br />BUSINESS NAME (Some as PacilirvA'ameor DDA - Doing Business As)
<br />USA/Tesoro 68151
<br />BUSINESS SITE ADDRESS CITY
<br />104
<br />35 N. Cherokee Lane I Lodi
<br />11. TANK DESCRIPTION
<br />LANK TANK MANUFACTURER 433
<br />TANK CONFIGURATION: I -FLISTANK IS
<br />4,14
<br />3 Trusco
<br />0 L ASTAND -ALONF. TANK p1b,
<br />�ch
<br />each
<br />0 2, ONE INA COMPARTMENTED UNIT comi,ant i,, the uric.
<br />DATE UST SYSTEM INSTALLED 4:5 'TANK CAPACITY IN GALLONS 436
<br />NUMBER OF COMPARTMENTS fNTHE UNIT
<br />1995 0 10100L_
<br />IH. TANK USE AND CONTENTS
<br />TANK USE 0 la, MOTOR VEHICLE FL7ELING [] ib, MARINA FUELING C3 1c.AVIATION FUELING
<br />4
<br />C1 3 CHEMICAL PRODUC-LSrORAGE 0 4 HAZARDOUS WASTE (1-Wdes (_,ed Oil) 0 5,1- `NIFRGFNCY GFNERKI'OR FUEL itisc §2s281
<br />(Cr,
<br />0 6 OTITER GENERATOR FLAT UNKNOWN 0 99� OTHER (Specify):
<br />CON ,-rFNfS PE I ROI,EU!M, 0 h. RIG ULARUNLEADI-J) C] 1c.NIIDGRADFUNLEADED 1 b, PREM II ljN1.:FADED
<br />DIESEL, C] 5 JET FUEL 0 6.AVIA rION GAS
<br />0 8 PEI ROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify), as 3a
<br />0 N- P Erk&FU�T,T. E]-'7 USED 0, IL, 10 ETHANOL
<br />ILOT 440b
<br />IV. TANK CONSTRUCTION
<br />TYPE ()I, TANK E] I SINGI I-. WALL,
<br />443
<br />PRIMARY I C 1 0 1 N T I - I - NM I 11 E I N I T 0 1 1, s , rFEL. C1 3. Ff I BFRGLASS 0 6. IN -1 -ER N AL BLADDER
<br />414
<br />❑'7, STEEL INTERNAL LINING 0 95 UNKNOWN 0 99, OTHER'(Specift): _444j
<br />SECONDARY CONTAINMENT C] I STEEL [13. FIBERGLASS C] 6, EXLERIOR ,MEMBRANE-: LINER 7, JACKETED
<br />90 NONL [3 95 UNKNOWN Ej 99, oTFIER (SpecuFy) 44 Sa
<br />OVERFILL PREVENTION 1, AUDIBLE& VISUAL ALARMS❑2,13ALL. FLOAT 3, FILL TUBE SHUT-OFF VALVE
<br />C] 4 TANK N4EETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PRE VENTI
<br />V. PRODUCT / WASTE PIPING CONSTRUCTION
<br />NSrRUCTION 0 1 SINGLE WALL 2. DOUBLE W ,
<br />PIPING CO ALL ❑ 99OTER
<br />460
<br />GRAVITY -
<br />YPE 1 PRESSURE ------0'--3CONVENTIONAL SUC HON 0 4 SAFE SU TO (13 CCR263N#3)j
<br />TEMT
<br />57
<br />--C--2--,
<br />lk NNF&f o 1STEEL ®4 FIBERGLASS 0FLEXIBLE 0 10, RIGID PLASTIC
<br />4(4"
<br />E] 90, NONE 0 95, UNKNOWN ❑ 99, OTHER (Specify): 464a,
<br />'SE`C6KDARY CONTAINMENT Ej 1,
<br />IS0 8 E 0 10, RIGID PLASTIC90,
<br />NOE 95,UNKNOWN 0 99. OTHER (Specit�,). 464PIPINGTFURBINE
<br />TYPE
<br />1 2 11 DOUBLE , E . WALL , " 0 90. NONE
<br />CONTAINMEN_ r S6Ni0I._S1NWA-L-L❑
<br />4644 I
<br />VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION
<br />L__
<br />VENT PRINIARY CONTAINMENT 1, STEEL 0 4. FIBERGLASS 0 TO- RIGID PLASTic El 90 NONE El 99 OTHER (Specify)
<br />464e
<br />464e I I
<br />VENT SECONDARY CONTAINMENT C] I STEEL C1 4. FIBERGLASS ❑ 10 RIGID PLASTIC 90 NONE 0 99 OTHER (Specify)
<br />404t
<br />RAT, 1
<br />. .....
<br />VR PRIMARY CONTAINMENT ❑ 1 STEEL ®4 FIBERGLASS 0 10, RIGID PLASTIC 0 90, NONE 01), ) .11 O'll'HE,Rl-("Spewfv,),:�§��911
<br />464g
<br />VR SECONDARY CONTAINMENT E] 1, SJTE 1, 0 4 FIBERGLASS 0 TO. RIGID PLASTIC C3 90. NONE 0 990'111LR(Spccityl�
<br />464h
<br />464h!
<br />VENT PtPING_TRA_NSTF ION SUMP TYPE 0 1,- SINGLE WALL- 0 2.DOUBLE1 1 . .1 WALL 90 NONE
<br />RISER PRIMARY CONTAINMENT 0 1. STEEL C]4. FIBERGLASS 0 10. RIGID PLASTIC ❑ 90 NONE ❑ 99 oTtLER (Specify)
<br />464
<br />46�4j
<br />RISER SECONDARY CONTAINMENT C] i.smEL 0 4 FIBERGLASS ❑0 10. RIGID PLASTIC 90. NONE ❑ 99. OTHER (SpecifvL
<br />_j
<br />464k,
<br />4tAk I
<br />. ........... ... .
<br />FILE COMPONENTS INSTALLED 1, SPILL BUCKET STRIKER PLATErBOTTOM PROTECTOR ❑ 4.
<br />451
<br />VIL UNDER DISPENSER CONTAINMENT (UDC)
<br />CONSTRUCTION TYPE I � SINGLE WALL 0 2. DOUBLE WALL 0 3.N0 DISPENSERS 0 90, NON , E
<br />469.
<br />....... .... ---------
<br />CONSTRUCTION MATERIAL I. STEEL ❑[1 4. FIBERGLASS ❑0 10, RIGID PLASTIC ❑0 99, OTHER (Specify)
<br />Vill. CORROSION PROTECTION
<br />STEEL COMPONENT PROTECTION ANODE(S) ❑ 4. IMPRESSED CURRENT ®6. ISOLA'CION
<br />4as
<br />_�SAC�RIFICIAU
<br />IX. APPLICANT SIGNATURE
<br />CFR'riFIC.ATION- 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 cam fiance with I a, rea�tuurelmocnts.
<br />c a and"in
<br />—
<br />S
<br />APPLICANTSIG'NATURE
<br />A
<br />E=
<br />DATE 2/8/2010
<br />470
<br />A N k F (p i y S
<br />APPLICANTNANIE (print) Sandy E ards
<br />APPLICAN'TTITLE Environmental Compliance
<br />472
<br />UPCIF UST -B Rev. (12f2007) - 112 www.unidocs.org
<br />
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