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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TY E OF ACTION (Check one item only. For an UST permancrt closure or removal,completeonly this section and Sections I,11,III,IV,and IX below) 430 11.NEW PB?A4iF1e0Rw1 ❑ 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& DATE EXISTING UST DISCOVERED: 430b T. FACILITY 1NFoRMAol�i. FACILITY ID#(Agency Use Only) _ 1 7 C BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 UIK STOP MARKET#148 BUSINESS SITE ADDRESS 103 CITY 104 205 WEST LOCKEFORD STREET LODI IC TANKDESCRIPTION _ TANK ID# 432 TANK MANUFACTURER 433 TANSC CONFIGURATION: THIS TANK IS 434 #1 (RUL,87 OCTANE) XERXES V1.A STAND-ALONE TANK -TA#- ®22 Sits i ❑2.ONE IN A COMPARTMENTED UNIT. Complete one page for each com anment in the unit DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 JUNE 1,1988 10,000 1 III.TANK.USE-AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 (:1 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(includes Used Oil) ❑ S.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: Fla.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.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK'CONSTRVCTION TYPE OF TANK ❑ 1.SINGLE WALL DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL W 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL WING [195.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION C:11.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT PRODU /_WASTE.PIPING;CONSTRUCTION' PIPING CONSTRUCTION ❑L.SINGLE-WALLED W72.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE Irl.PRESSURE ❑ .GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(.x3)] 458 PRIMARY CONTAINMENT C1 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ K.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL dr 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ ?2.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE WI.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d DI.VENT,VAPUR RECO.,.,_-_.&ft`I A-NDRISER41IILL,PIPE PIP PTCse�CONSTRUCTION. VENT PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 46421 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE ❑ SINGLE WALL 2.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT 1.STEEL U 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 464'I RISER SECONDARY CONTAINMENT ❑ 1.STEEL (1 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 4644 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR4.CONTAINMENT SUMP 45la-c VII.-UNDER DISPENSER CONTAINMENT'W_DC)- = CONSTRUCTION TYPE SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469& CONSTRUCTION MATERIAL 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 99.OTHER(Specify) 4696-c vIDr. Co xQsYo�rPI�oT MON STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT jr6.ISOLATION 448. A...F, .,.. - .y..-g-. APPLICANT5IC�2A_TQ *' w 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 wit legal requirements. APPLICANT SIGNATURE DATE September 8, 2009 470. APPLICANT NAME(print) Mike,Karvelot, 471' APPLICANT TITLE Director, Environmental Affair* 472. for Quik Stop Markets,Inc. <: UPCF UST-B-112 Rev.(1212007)