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vt AL SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TY211 OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,III,IV,and D(below) 430 1.NEW PEMI f Fd^#-t ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4303 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ _ IS 1 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 UIK STOP MARKET#152 BUSINESS SITE ADDRESS t03 CITY 104 1721-1 CHEROKEE LANE LODI 1 14111171 U.TANK DESCRIPTION TANK ID# 032 TANK MANUFACTURER 433 TANI CONFIGURATION: THIS TANK IS 434 #2 XERXES El.A STAND-ALONE TANK ❑2.ONE IN A COMPARTMENTED UNIT. Tv Complete one page for each ccuVxtn=t in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 DECEMBER 6 1988 10,000 1 III.TANK USE AND CONTENTS TANK USE 1 a.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ S.EMERGENCY GENERATOR FUEL IHSC§2528 L5(c)l ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED .MIDGRADE UNLEADED lb.PREMIUM UNLEADED (0 (l JZ 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).. UOb IV. TANK CONSTRUCTION TYPE OF TANK ❑ L SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT [1 1.STEEL Jr3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNALG E] 95.UNKNOWN C199.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify) 445a OVERFILL PREVENTION ❑ I.AUDIBLE&VISUAL ALARMS 2.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-WALLED DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR§2636(ax3)I 458 PRIMARY CONTAINMENT ❑ I.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 PIPING/TURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ L STEEL W4.FIBERGLASS ❑ 10.RIGID PLASTIC Ej 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464f 464tt VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4646 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ .SINGLE WALL [12.DOUBLE WALL 90.NONE 464i. RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 46 j RISER SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED L SPILL BUCKET W3.STRIKER PLATE/BOTTOM PROTECTOR W4.CONTAINMENT SUMP 45ta-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 7 44,W. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.54PRESSED CURRENT 6.ISOLATION A48• 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,ao or" and in full compliance wi!k legal re uire nts. APPLICANT SIGNATURE „i1j✓J DATE August 24, 2009 E- X70 APPLICANT NAME(print) Mike�♦Karvelot� 47I. APPLICANT TITLE Director, Environmental Affairs F 472. for Quik Stop Markets, Inc. ° I N�' UPCF UST-B-112 rV1)Ut/ c Rev.(12!2007) r�M�" V o