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IED PROGRAM CONSOLIDATED FOIF 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 1,11,111,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 DATE UST PERMANENTLY CLOSED: a3oa. DATE EXISTING UST DISCOVERED: 430b. I. 'FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. Tesoro/Shell 68151 BUSINESS SITE ADDRESS 103. 1 CITY OCT 0 _ ZU12 too. 35 N. Cherokee Lane Lodi II. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. 3 TI USCO ® 1.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 ❑ 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)I ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a. - .........._.._..............--.......... ....._............_................-... ------ .......... -.._.-..........-----.................__...----...._.__........................._......_..._...__._.... ................_....... _........... CONTENTS PETROLEUM: ❑ [a.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ® lb.PREMIUM UNLEADED aao. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440a. -... -.. ------- _._.._..........__..............................._............._......._._.._............................................................................................ -_._................... NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION 43. TYPE OF TANK _._� 1.SINGLE WALL ® 2.DOUBLE WALL ..❑ 95 UNKNOWN ............ .. ..-........ _... _...................... -- -........... .4 PRIMARY CONTAINMENT ® I STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444a. _............._....._................__........._......__.._........_..... _..._..........._............................_.._..__....................-_._..._.............................._..__....................._.__...._..................--- ___......_._._......_....._..._... ---- ............. ........... ........--4 .... SECONDARY CONTAINMENT ❑ L STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ® 7.JACKETED 4a5. ❑ 90.NONE ❑ 95;UNKNOWN ❑99.OTHER(Specif.. _................----._..... OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS [12.BALL FLOAT ® 3.FILL TUBE SHUT-OFF VALVE a52. ❑ 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 460. ........ ............---.............----- --------....._.__._..._....._..........._....._......_...................................__._._............................ -...................- -......__......._...__..._........._....... SYSTEM TYPE _®..._1.:._PRESSURE 2.GRAVITY [ 3..CONVENTIONAL SUCTION 4_SAFE SUCTION[23 CCR§2636(a)(3)) _....__....._4......:..... _....... ..... ......... -..._. ............ PRIMARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS [18.FLEXIBLE ❑ 10.RIGID PLASTIC aha. ❑ 90.NONE [195.UNKNOWN El 99.OTHER(Specify): 464a. ( Pe fY) ._...........--_..........._......_.._... SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC a6ab. _❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4�0 ............................ ....._...........I... ... ... ... ..............._................._........._-....._----..........._....._._._.............._......- ---.._...._....- -- _................ PIPING/TURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE a64d. VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION .VENT PRIMARY CONTAINMENT ® L STEEL ❑ 4.FIBERGLASS [310.RIGID PLASTIC ❑ 90.NONE E] 99.OTHER(Specify): 464et464e. . : -...............__......_._..._.................._.._....__......_......__...'--..._...........---.................._......._........................__.._..-.--------._.....-----.............--'.._._................----.._..........................._................__............._....................................---------..........._----......._...-.... VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 46 fl_:._.__ .................._.........__....._._...._........_..._.....__..._.__._.....__..........----..................----................................_.........._............................----................---......_.._..-..__....._...__...................................._..........._...................._............. 464g. VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90 NONE ❑_99_OTHER(Specify): gbaBl ...................... ......_. ---- ........... ................................... .....................----......... ..... VR SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90 NONE ❑ 99 OTHER(Specify) 464h1.,,,,. ..........._...._..................._..............._....._._................_.........._..........._....................-----.................................--._.._...-.............._........._...._..............................._._............................................................ ........---_.._.__.. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 46a,. _ _ _ _ _ _ ........................................._...........................--_._..._-----------.--.-__._.__-_..-._.._._............................................_....._..................................--......_.........._........................____......_._-....................._._..ate)_.... RISER PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE El99.OTHER(Specify): 464j1, ...................................__..._........._............-.....----._....-.----.._..............._._..__.........................................._............._..---...................-_._................._.---.._.....---..._......._..---._...--..-.---'._.................._........_.----..__..___....-.__................._....._ 464k. RISER SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4 (Specify):.FIBERGLASS [1 ]0.RIGID PLASTIC ® 90.NONE 99.OTHER(Spe fy) 464k1, FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATEIBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45ta-c. VII. UNDERDISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL - __ ❑ 2 DOUBLE WALL ❑ 3.N..DISPEN.. ........ ._.........._....__......_._...................4696.. CONSTRUCTION MATERIAL ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c. 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 reflairememls"' - 470. APPLICANT SIGNATURE 1 DATE 1/']/201 j APPLICANT NAME(print) S 471. APPLICANT TITLE Environmental Compliance 472 J �� § tri u-3,.`0f-, UPCF UST-13 Rev.(12/2007)-1/2 www.unidocs.org L_ZA