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qf/ y UNIFIED PROGRAM CONSOLIDATED FORM I UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one tom,Per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only Ibissection and Sections 1,11,III,IV,and IX below) 4)0 ❑ I.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.•TEMPORARY USTCLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4304 1 DATE EXISTING UST DISCOVERED: 4106 1. FACILITY INFORMATION FACILITY ID N(Agency Use oa131 _ BUSINESS NAME(Same as FACILITY NAME,or DBA-Doing Business As) 3 Rancho San Miguel BUSINESS SITE ADDRESS 1m C17Y lot -62".Cherokee Lodi It.TANK DESCRIPTION TANK ID I) TA 05115701 433 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 414 K&T ❑ I.A STAND-ALONE TANK ®2.ONE M A CONIPARTNIENTED UNIr. Cam lets on Wreazh cam mens In aeuna DATE USI'SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 433 2004 5000 2 M.TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 Q 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(In w.Used on) ❑ 5.EMERGENCY GENERATOR FUELIFISCI2526I.5(4)1 ❑ 6.OTHER GENERATOR FUEL ❑ 95 UNKNOWN ❑ 99.OTHER (Specify: 439' CONTENTS PETROLEUM: ❑ ]a.REGULARUNLBADED ❑ k.MIDGRADE UNLEADED DO Ib.PRFMIUMI/NLEADFD N9 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 4404 NON-PETROLEUM:❑ 7.USED OIL ❑ METHANOL ❑ II.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPEOFTANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARYCONTAINMENT ® I.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN 0 " 99.OTHER (Specify): 444' SECONDARY CONTAINMENT El 1.STEEL D9 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.1ACKF.TFD 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify) 44sa OVERFILL PREVENTION 9 I.AUDIBLE R VISUAL ALARMS I& 2.BALL FLOAT 3.FILL TUBE SHOT-OFP VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVP.NTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED ®2.DOUBLE-WALLED ❑99.OTHER 40 SYSTEM TYPE ® 1.PRESSURE (7 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION 4.SAFE SUCTION 11 CCR 2N6(y(3g 453 PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ® S.FLEXIBLE ❑ to.RIGID PLASTIC 461 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(S ci ): 461s SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ® 9.FLEXIBLE ❑ to.RIGID PLASTIC JNb ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4Nc PIPING)TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4W VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT I7 1.STEEL ® 4.FIBERGLASS IO.RIGIDPLASTIC 0 90.NONE 0 99.OTHER(SPecify) 4Ne 4Ne1 VENT SECONDARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC 0 90.NONE. ❑ 99.OTHER(Specify) 4Nr 4Nn VR PRIMARY CONTAINMENT ❑ 1.STEEL El 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE CI 99.OTHER(Specify) 4Ng 4&1,1 VR SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS 13 ID.RIGIDPLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 4Nh 4Nhl VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL 0 2.DOUBLE WALL ® 90.NONE 4NI. BSER PRIMARY CONTAINMENT I.STEEL 4.FIBERGLASS ❑ 10.RICll3 PLASTIC 4" 90.NONE 99.OTHER(Specify) 4 RISER SECONDARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC ® 90.NONE 0 99.OTHER(Specify) 4NI 4Nk1 FILL COMPONENTS INSTALLED ® LSPB.LDUCKET ® 3.STRIKER PLATEMOTTOM PROTECTOR ® 4.CONTAMMENT SUMP Jsl.< VU.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 9D"NONE 4690 CONSTRUCTION MATERIAL 0 L STEEL ❑ 4.FIBERGLASS C9 IO.RIGID PLASTIC ❑ 99.OTHER(Specify) 46 VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that 11 s .•sys 1 I o Patible With the havardom substance stored and that the information provided bevel true,accurate, and in full i x' h leg a iramanh. APPLICANT SIGNATURE DATE 12/10/2009470. x•;,4 APPLICANT NAME(print) Gilbert IIVa 4]l. APPLICANTTtTLE Contact - ^ ;j� 4T2. UPCF UST-B-1/2 - Rev.(12/2007)