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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) T�OF ACTION (Check one item only. For an UST permanert closure or removal,completconly this section and Sections I,II,III,IV,and IX below) 430 E 1.NEW+EP4iW- IrORM ❑ 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 DATE EXISTING UST DISCOVERED: a3ob I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 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 _`. .,��nT�'DESCRII'TYON TANK ID# 432 TANK MANUFACTURER 433 TAN CONFIGURATION: THIS TANK IS 434 #2(UNL PLUS,89 OCTANE) XERXES Arl.A STAND-ALONE TANK [12.ONE IN A COMPARTMENTED UNIT. U Complete one page for each compartment 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.T . ANK USE AND'CO�'Y'ENTS TANK USE rla.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)1 ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED jrIc.MMGRADE UNLEADED ❑ Ib.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): 4a0b i Iv.,TANK CONS4IRUCTION . TYPE OF TANK C11.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL Ir 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINNG ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ L STEEL ffir3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a 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. PRODUGTI,WASTE PII'IN0 GONSTRUGTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED .DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ .GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)1 45s PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ ?;.UNKNOWN ❑ 99.OTHER(Specify): 464s SECONDARY CONTAINMENT ❑ I.STEEL Ir4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE WI.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAP OR;RECO%- ]_X( It)AND RISER"kML PIPE Pll'ING CONST�'VCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL gr4.FIBERGLASS ❑ 10.RIGID PLASTIC Ll 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC U 90.NONE ❑ 99.OTHER(Specify) 464f 464fl VR PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464g I VR SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) a64h64h1 1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 464' RISER PRIMARY CONTAINMENT Ir 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 464'I RISER SECONDARY CONTAINMENT ❑ 1.STEEL C3 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED irf SPILL BUCKET Vf STRIKER PLATEBOTTOM PROTECTOR e4.CONTAINMENT SUMP 451a-c ' 'VII.�JNDERDISPENSER�CONTAINMENT t�LTDC);, , CONSTRUCTION TYPE Vj SINGLE WALL El2.DOUBLE WALL C13.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL NrLSTEEL ❑ 4 FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) "; f0b-c `V�IIL��CORROSIONY.�OT.�„CTION;,x. STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT6.ISOLATION �p 448. IX. APpI: G�AISIG ' TRE .,; m CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is truei°accurate, and in full compliance with 1 al re uiremen . APPLICANT SIGNATURE,+� DATE September 8,2009 47�. APPLICANT NAME(print) Mike KarVelot, 471. APPLICANT TITLE Director, Environmental Affairs 472. for Quik Stop Markets, Inc. UPCF UST-B-1/2 Rev.(12/2007)