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FIED PROGRAM CONSOLIDATED FOW 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,A III,IV,and IX below) 430. ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ® 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL ATE UST PERMANENTLY CLOSED: 43oa. DATE EXISTING UST DISCOVERED: F4306. L FACILITY INFORMATION FACILITY ID#(Agency Use Onl}) I BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. Tesoro/Shell 68152 BUSINESS SITE ADDRESS 103 CITY 104 401 W. Kettleman Lane Lodi XI. TANK DESCRIPTION TANK 1D# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434' 2 TrUSCD [:11.A STAND-ALONE TANK Complete one page for each ❑ 2.ONE IN A COMPARTMENTED UNIT compartment in the unit. DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. 1998 14,000 1 III. TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ lc.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................................-..._._._.__................-'---..._....-.._): CONTENTS PETROLEUM: la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ��b.PREMIUM UNLEADED a40. 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL [19.OTHER PETROLEUM(Specify): 44oa. NON-PETROLEUM:❑ 7.USED OIL ❑ ]0.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406. IV. TANK CONSTRUCTION TYPEOF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOW ........... ..................................................__......_....._..............._.-...-_._..............----.........._..---......._.._._.....-'----.___.............I PRIMARY CONTAINMENT ® 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 4 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444.. -....-_..............................._-........_...__........-......--. .... - ........_....................--' -.._......_........._.........__.._... ._.-.....--_..............._..-.._.._...._........................_.._._...................._._........_.__.._............................... ........... SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ® 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 44sa. __.............__.._..._.....-.....-.._....__.._..._.__....................__. ....................._............................-_..__.._......-_....... --.-._.......__.......................• ---._....----_._.......... _..._.............__._.... 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/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ....i SINGLE WALL ®._2,DOUBLE WALL 99-OTHER . _._.. 460. _.._.....--._...._.-.__........-_.... .........-- SYSTEM PRESSURE ❑ 2 GRAVITY O.3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(.x... 458 PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN El 99. (Specify):99. ER ................. SECONDARY CONTAINMENT ❑ ].STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4.... _.....-' ........._..._............._.-..................---....._...........................................................--..•.__..._..................---........................_......_...._..............-'-----..... _..._._._...._..-...__. PIPING/TURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d. VI. VENT,VAPOR RECOVERY(VR) AND RISER/FILL PIPE PIPING CONSTRUCTION 464e. VENT PRIMARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90_NONE ❑ 99.OTHER(Specify): 464e1,,,.... . . .....................................--"_- .....-..-_.._.._..-_.........._ .._....---__.__._..._._....................._....._................._............................._.............. 46 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4 FIBERGLASS ❑ 10.RIGID PLASTIC ® 90 NONE ❑ 99 OTHER(Specify) 46q 1. _...... ......... ..-.. .... .__ ..._._.__........._.........._........_............_...-----........-------..._.----------'-------.._........_......_............_..............._............_......................................_........-...-. 4649. VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): Q64B.l.:...... -..............._..-....._-..._...............-....... _........_......__..._..-_._..._._..._._..... -......__.._-...._--._..._.__......................._-.-...........................--'--..._......._..___....._.__....._._................-'---'---._..-._.................................•...--'-................... .bah. VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464h1. --..................._..._.__.............._...._._._.-.._._......_....._..'----'----..........--------"--.........-..._._....'---'_................._... -'----'--'-----_..._...............----'-_.-._._._.._._......................_.._..-................._. 4641....... VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE abal. __..............--.....................I..._. -._.._........ _..._-.... -----'-'- ----_. _. _..__.._. . .---......-._........__...-...........................__..........._........_.............................._.-....-................................._..............................._.__.................._........ ........._.....-..._..........464j. .. RISER PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): gbq�j _ ..........................................................---............_........._...-_..-......................................................................._....._._........................_.........._.__.._.-.__.............._...----...... 464k. ..............I.. .......... ............. ......................_.........__..............._._...._._...---.._._...._............._..._. RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464kt: _ _..................................__..-....................._-_........-......._................__................._..-._.._............-'- ._........__._.._....................................................._......................-'----._......._.......................----..._........_............_-_....FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® 1:SINGLE WALL -_ ❑ 2.DOUBLE WALL ❑ 3.NO DISPEN................................................. . _._.....---_. ...._.... _....._......._._.._...._-..._-._..-.__..__..-...-.... � 4696. CONSTRUCTION MATERIAL ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES ❑ 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 r 470. APPLICANT SIGNATURE DATE 1/']/201 1 APPLICANT NAME(print) �,�J 4" APPLICANT TITLE Environmental Compliance r 4�2 UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org 4 04 (1 I^