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POW low UNIFIED PROGRAM CONSOLIDATED FORM . UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per USTI ) ID a TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section aid Sections 1,11,111,IV,and IX below) 4.30 ❑ L NEW PERMIT 0 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: 1396 I. FACILITY INFORMATION FACILITY IDA(AgencyUse Onf}) _ BUSINESS NAME(Sone,as FACILITY NAME or DBA-Doing Business As) 3 Rancho San Miguel BUSINESS SITE ADDRESS Io305CITY 10/ 62 .Cherokee Lodi H.TANK DESCRIPTION TANK IDN TA0511570/ 452 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS u4 O KR.T ❑1.A STAND-ALONE TANK 0 2.ONE M A COMPARTmiiNTED UNrr. Ca9lete. efx each mm in no wit DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 457 2004 150-002 M.TANK USE AND CONTENTS TANK USE 0 Is.MOTOR VEHICLEFURLING ❑ Ib.MARINA FUELING ❑ to.AVIATION FUELING 439 _ ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Isciudes Used Oa) ❑ 5.EMERGENCY GENERATOR FUEL(HSC 425281.5(0)1 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 43% CONTENTS PETROLEUM: 0 Ia REGULARUNLEADFD ❑ l9.MIDGRADE UNLEADED ❑ 3b.PRimiumuNLEADED as ❑ 3.DIESEL ❑ 5.3ETFUFL ❑ 6.AVIATION GAS ❑ &PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify); aoa NON-PETROLEUM: 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUMS i ' Ji06 IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLEWALL 0 2.DOUBLEWALL [395.UNKNOWN 443 PRRNARYCONTA(NMENT 0 I.STEEL ❑ 3.FIBEROLA5S ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (specify), 44 SECONDARY CONTAINMENT ❑ LSTEEL 03.FIBERGLASS U 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 47s ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER S try): 44% OVERFILL PREVENTION 09 1.AUDIBLE&VISUAL ALARMS 02.8ALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MELTS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑I.SINGLE-WALLED 0 2.DOUBL&WALLED ❑99.OTHER 460 SYSTEM TYPE 0 LPRESSURE Q 2.0RAVITY 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION lel MR g2636(a)(3)) 459 PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS 0 u.FLEX3BLE El 10.RIGID PLASTIC 4e, ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHERS if : 46A SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS 0 8.FLEXIBLE I] 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4649 PIPINGRURBINE•CONTAINMC•NT SUMP TYPE ❑ I.SINGL6 WALL E32.DOUBLEWALL ❑ 90.NONE 4676 VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT U LSTEEL 99 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify 4619 4641 VENT SECONDARY CONTAINMENT ❑ [.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 4wf Own VR PRIMARY CONTAINMENT 0 I.STEEL 0 4.FIBERGLASS El 10.RIGID PLASTIC E3 90.NONE ❑ 99.OTHER(Specify) -8 VR SECONDARY CONTAINMENT 0 I.STREL 0 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 4wh 4whl VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 4W RISER PRIMARY CONTAINMENT 0 I.STEEL S.FIBERGLASS 10.RIOID PLASTIC 90.NONE 99.OTHER(Specify) 4e,) e,1 RISER SECONDARY CONTAINMENT 0 I.SIEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 090.9ONE 99.OTHER(Specify) 464k 467k1 FILL COMPONENTS INSTALLED 0 1.SPILI,BUCKET 14 3.STRIKER PLATF/BOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 451• VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 0 1.SINGLE WALL ❑ 2.DOUBLE WAf.L ❑ 3.NO DISPENSERS ❑ 90.NONE 4690 CONSTRUCTION MATERIAL El I.STEEL ❑ 4.F®ERGLASS C9 I0.RI01D PLASTIC 0 99.OTHER if a696c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑4.IMPRESSED CURRENT ❑ 6.ISOLATION 449. IX APPLICANT SIGNATURE CERTIFICATION: 1 certify that 1 ' ysten mpatible%4th the hazardous substance stored and that the information provided her ' is true,accurate, and In full c 1 . eith i 1 uirements. APPI,ICANTSIGNATURE DATE 12/10/2009 47°' APPLICANT NAME(print) Gilbert$IIVa X71' APPLICANTTITLE Contact i71 UPCF USI--B-12 Rev.(12/2007)