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IED PROGRAM CONSOLIDATED FO UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (one form per UST) FTY�PEOFACTIION (Check one item only. For a UST closure or removal,complete only this section and Sections I,A III,IV,and IV 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: 430a. I DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ - '4 1 1. BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. MCI, dba, Verizon Business BUSINESS SITE ADDRESS 103. 1 CITY 104. 13850 N. DeVries Road Lodi H. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. 1 `�R 6l�l�o i Xerxes ® 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. 1985 550 1 III. TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ lb.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: ❑ 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): 440a. .............................................................................................................................- .._...................._............................................................................................................................................................................................._.................. ............................................. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHERNON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443. ................................................................................................................... ........................................_........................_.._.................................................__._......................-.......-.................................................................................................................................................................................................-.................................................................................. PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN [_199.OTHER(Specify): 444a. ................................................................................................_.........._._........................_._..........................................................__._........................................................................................................ .................................. ... SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ &EXTERIOR MEMBRANE LINER [17.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): a45a. ............................................................................................................._..._..........................................._.................__.._................_.._..__......_.................................... ........................ OVERFILL PREVENTION ® 1.AUDIBLE&VISUAL ALARMS [12.BALL FLOAT [13.FILL TUBE SHUT-OFF VALVE 452. [3 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. ..................................................................................................-...............................----._.................................................................................................................-..................................................................................................._.._._....................._-....... .................................._........__._._.......................................................... 458 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY ® 3.CONVENTIONAL SUCTION .[_1 4:_SAFSAFE SUCTION[23 CCR§2636(a)(3)] 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 ❑ 10.RIGID PLASTIC 464b. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. __.._.._._..........................._.........._........................................................._......._................................................................................ ....................................................... PIPINGlrURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d. VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION 46 VENT PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464e1. ..................._...................................._............................................................. .....4...4....... VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464fl. .....................---.............................................................................................................................................................................._..................._.__............................................._................................................ ...4...4...:_.. VR PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464gg,.-. ...................................................................................................._....._....................._..............._..............................._......._.__..........................._...................................................................................................................................................................._._................................................................................................ 4 4 VR SECONDARY CONTAINMENT [11.STEEL ❑ 4.FIBERGLASS [I10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464hl ...................................................................................................................................................._......._.._............................-. _........................................._............................................................................................................................................... VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 464i. ......................................................................................................................................................................................---...._...__............................................................................................................................................................................................... ,...._ 4641. RISER PRIMARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464jk...., RISER SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464kl. ........................._..................._..._..................................................-._.._........................._......................................................................................................................................................................................................................... ..................... 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: 469a. ......................._.................._................................................................................................................._..................................................................................-_..._...................__..............._ .._ . . ...................................................................... . ................................................................... ........................................ CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) a,"I'll 469c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION r} 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provideLogein is true, accurate and in full com li ce with legal requirements. APPLICANT SIGNATURE _�9 ,1 DATE 8/12/2010 I 470. APPLICANT NAME(print) Todd Harris 471. APPLICANT TITLE Regional Environmental 4Ner 472