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IED PROGRAM CONSOLIDATED FOAW UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (one form per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal, complete only this section and Sections 1, II, 111, IV, and IX below) 430. ❑ L NEW PERMIT ❑ 3. RENEWAL PERMIT ® 5. CHANGE OF INFORMATION ❑ 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 430.. 1 DATE EXISTING UST DISCOVERED: 4306, L FACILITY INFORMATION FACILITY ID # (Agency Use Only) 1. BUSINESS NAME (Same as Facility Name or DBA - Doing Business As) 3. USA/Tesoro 68151 BUSINESS SITE ADDRESS 103. CITY 104. 35 N. Cherokee Lane Lodi II. TANK DESCRIPTION TANK ID # 432. TANK MANUFACTURER 433, TANK CONFIGURATION: THIS TANK IS 434. j TTUSCO ® 1. A STAND-ALONE TANK Complete one page for each ❑ 2. ONE IN A COMPARTMENTED UNIT compartment m the unit. DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437, 1995 12,000 IIL TANK USE AND CONTENTS TANK USE ® la. MOTOR VEHICLE FUELING ❑ lb. MARINA FUELING ❑ Ic. AVIATION FUELING 439. ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 5. EMERGENCY GENERATOR FUEL [HSC §25281.5(c)] ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify) 439a. .......... .. ............ .................. ............. ..................................................... ........... ............. .......... .............. CONTENTS PETROLEUM: ® la. REGULAR UNLEADED ❑ lc MIDGRADE UNLEADED ❑ lb. PREMIUM UNLEADED 440 ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9 OTHER PETROLEUM (Specify)_ 440.a . ....... NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ❑ 11. OTHER NON -PETROLEUM (Specify): 4406. IV. `'TANK CONSTRUCTION TYPE OF TANK ❑ 1 SINGLE WALL ® 2 DOUBLE WALL ❑ 95 UNKNOWN 443' .. ....... . ............. ................ ...... ....... .......... ............ 44a PRIMARY CONTAINMENT ® 1. STEEL ❑ 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 4aa ❑ 7. STEEL + INTERNAL LINING El 95. UNKNOWN El 99. OTHER (Specify): a . SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ® 7. JACKETED 445. 445a. ❑ 90. NONE❑ 95. UNKNOWN ❑ 99. OTHER(Specify): ..................................................._.._.._.....__.........................._.........._.__._..........r... ......................_..__.................._........_........................................... .____.__ _. OVERFILL PREVENTION ❑ 1. AUDIBLE & VISUAL ALARMS ❑ 2. BALL FLOAT ® 3. FILL TUBE SHUT-OFF VALVE 452. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT I WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1. SINGLE WALL ® 2. DOUBLE WALL [1 99. OTHER 460. .................................................................. . SYSTEM TYPE ® 1. PRESSUREO._2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR §2636(a)(3)] 458. ......................... PRIMARY CONTAINMENT El 1. STEEL ® 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464. ❑ 90. NONEUNKNOWN OTHER (Specify).:..._. 464a. ...... ... ........... ..............._..._._.......❑.._95 ..._........._._....❑..._99 SECONDARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 4646. ❑ 90. NONE 95. UNKNOWN OTHER (Specify):..._. a64c. ................................ ... ........ ................................. ............_0 .......................0..._99:.. PIPING/TURBINE CONTAINMENT SUMP TYPE ® 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE 464x. 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 ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ® 90. NONE ❑ 99. OTHER (Specify): 464n .......... ..............................................................................................................................................................................................................................................................._....................................__..................................................................................-......... ......................................................................... 4648. VR PRIMARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS [110. RIGID PLASTIC [190. NONE [1 99. (Specify): 46481, ................. .................... .............. VR SECONDARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 464h1. .............................................................................................................................................................................................................................................................................................................................................................................................................. ...................................................................................... 4......;....... VENT PIPING TRANSITION SUMP TYPE ❑ 1. SINGLE WALL ® 2. DOUBLE WALL ❑ 90. NONE 64` .......... .. .................... - .. .......................... .......... ...... ............. ... ........... .............. .. ......... RISER PRIMARY CONTAINMENT ® 1. STEEL ❑ 4. FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify). 4644] .... ............... ... .............................. .............. ........ ..... .......... .................. .-........ ..................... .................. ........... .................. ........... .......... 46441...... RISER SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ® 90. NONE ❑ 99. OTHER (Specify): 4644. ....... ...................... ................ .................. FILL COMPONENTS INSTALLED ® 1. SPILL BUCKET ® 3. STRIKER PLATE/BOTTOM PROTECTOR ❑ 4. CONTAINMENT SUMP 45la-c VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3 NO DISPENSERS ❑ 90. NONE 469a. ........................................................................................................-........................................................................................................................................_._............................................................................................ ......... CONSTRUCTION MATERIAL ® 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 4696. 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 S DATE 2/2/2009 470 APPLICANT NAME (print) Sandy Ed ards 471 APPLICANT TITLE Environmental Compliance 472. UPCF UST -B Rev. (12/2007) - 1/2 www.unidoes.org