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IED PROGRAM CONSOLIDATED FOIV 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 I,II,III,IV,and IX below) 430. WATI.NEW PERMIT [:13.RENEWAL PERMIT ® 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE E] 7.UST PERMANENT CLOSURE ON SITE El 8.UST REMOVAL E UST PERMANENTLY CLOSED: 430a. DATE EXISTING UST DISCOVERED: 4306, I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) - 1 BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. Tesoro/Shell 68151 BUSINESS SITE ADDRESS 103. CITY 104, 35 N. Cherokee Lane Lodi TI. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:'CHIS TANK IS 434. 2 Tl USCD ® I.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. 1995 10,000 III. TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ Ib.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.OTHER(Specify): 439a. ........................................................................................................_............................................................................................................................................................_..... _...__..... CONTENTS PETROLEUM: ❑ 1a.REGULAR UNLEADED ® 1c.MDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 44.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. ..................................................................................._.........................._................._._...................................._.__........_.................................................................................................................................-................................_..................__...._........................__._..__..............I............. PRIMARY CONTAINMENT ® 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444a. �CONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ® 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER(Specify): 445a. .................................._..........................._................................................................................................................................................__........................_.............._........ .................................................. OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS El2.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 ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 99.OTHER ..........................................................................................................................................................................................................................................._....._..........._..._...__,_..................._.._........._...........abo... SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION [14.SAFE SUCTION[23 CCR§2636(a)(3)] 458. __........_. .. .......................................... ................................................................. PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a. _._......................._............_.._.__..._........................................................................................................................................................._._........................._..--........_._.............._..__..._............ _........_. SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ l0.RIGID PLASTIC 4646. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. ........................................................................................................................................................................................... ....................................................... PIPING/TURBINE CONTAINMENT SUMP TYPE. ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644. VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ® 1.STEEL El4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [199.OTHER(Specify): 464eel. ..............._............................_.................................................................................................................................................................._......................._..........._........................................._....................................................................................................................................................................................................... VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): g64n ......................................................................................._.......................__..__....._........__............._...__......................._............................................................................................................................................................... _.....g.... VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): qyI B' ................_....._._.._............................................................----.................................................................................................................................................__.................._......................................_........_.................._........_.................................................................................................................................. _.s....._. VR SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464hl. ..................................._..................................._...................._..........._._._.__.._.........................................._...................................................................................._.............................................._...._...._....._..._............._._.._................._.................................__..................._..__........................................... VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE .............................................................................................._......_..__..._....__....................._..........__._...............__......................................................................._......................................................................._..._......................._..........._._............_.....................-._.__.....__....................................................._...................................4�,_.... RISER PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464'1. ..................................._.................................................................._..........._._._..........__...........................................................................................................................................................................................................................................................__....I............................ .........1.......... RISER SECONDARY CONTAINMENT . k. .............. OTHER.............._................. ............................................................................__._.............................................................................................................................................................................................................. FILL COMPONENTS INSTALLED ® L SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL [:12.DOUBLE WALL [:] 3.NO DISPENSERS ❑ 90.NONE 469a. .........................................................................................................................................................................-............................................................................................................................................................._............................_.............................................................................................................................................................................. .................. CONSTRUCTION MATERIAL ® L 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. Ask IX. APPLICANT SIGNATURE ERTIFICATION: 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 APPLICANT SIGNATURE ATE 1/20/2011 4M APPLICANT NAME(print) APPLICANT TITLE Environmental Compliance I ` 72. ., UPCF UST-13 Rev.(12/2007)-1/2 www.unidocs.org Z d $