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V,((,A�I <br /> P 5-� <br /> A4oiPIED PROGRAM CONSOLIDATED FOIA 23-I0 <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) <br /> TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11,111,IV,and IX below) 430. <br /> ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: a30• DATE EXISTING UST DISCOVERED: 43%_ <br /> L FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) _ _ 1 <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> FLAG CITY ARCO/SUBWAY <br /> BUSINESS SITE ADDRESS 103 1 CITY IN <br /> 14931 NORTH FLAG CITY BLVD. LODI, CA 95242 <br /> II. TANK DESCRIPTION <br /> TANK ID# j 432. TANK MANUFACTURER 433- TANK CONFIGURATION:THIS TANK IS 434 <br /> TA0506224 ❑ L A STAND-ALONE TANK complete one page for each <br /> ❑ 2.ONE IN A COMPARTMENTED UNIT compa tment in the unit. <br /> DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 430- NUMBER OF COMPARTMENTS IN THE UNIT 437 <br /> 4/1/1997 10,000 <br /> III. TANK USE AND CONTENTS <br /> TANK USE S la.MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ In.AVIATION FUELING 439_ <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439.. <br /> CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ic MIDGRADE UNLEADED ® I1.b M PREMIUUNLEADED <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440a. <br /> NON PETROLEUM.❑ 7.USED OIL ❑ 10 ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUM(Sp,,-E). "In <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL S 2.DOUBLE WALL ❑ 95.UNKNOWN 443. <br /> PRIMARY CONTAINMENT ❑ I.STEEL S 3.FIBERGLASS ❑ b.INTERNAL BLADDER 444. <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444. <br /> -.-.-.... _______. _.___.-._-----..-..-._.. <br /> SECONDARY CONTAINMENT ❑ I STEEL S 3.FIBERGLABS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 845. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 4458. <br /> OVERFILL PREVENTION ❑ I.AUDIBLE&VISUAL ALARMS ❑ 2 BALL FLOAT S 3.FILL TUBE SHUT-OFF VALVE 452. <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVFNTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑ 1.SINGLE WALL S 2.DOUBLE WALL ❑ 99.OTHER 46o. <br /> __. ............. _--__ __.___._-. .......... .... -__ ----. _._-_ --'-'-._.... -....0 ........-.-.-... --458 <br /> SYSTEM TYPE S 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR¢z636(ax3)] 458. <br /> ......... ---_ '--______..._- .... .............. ................- .-...... .-.-. ....-........ ... -.-.-'-'- . 0.-1'-__-_. ___.. -......-.. .............. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL S 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.R1G[D PLASTIC 464_ <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. <br /> SECONDARY CONTAINMENT ❑ L STEEL S 4 FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC - 4646. <br /> _ ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER(Specify): 464c <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ I.SINGLE wALL ® 2.DOUBLE WALL ❑ 90.NONE 464d <br /> VI. VENT,VAPOR RECOVERY (VR) AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ I.STEEL S 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464 <br /> VENT SECONDARY CONTAINMENT ❑ 1 STEEL S 4 FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [199.OTHER(Specify): q4N <br /> VR PRIMARY CONTAINMENT ❑ I STEEL S 4 FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4668'. <br /> - ____.____ .....s...- <br /> VR SECONDARY CONTAINMENT ❑ I STEEL S 4 FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify).. abash_ <br /> ___ ___....... ............... .-.-.-. ..-.-.- -......-.... -.......... ........ ..-........ ._-______ ..-._-._...-.-.- .--4641. <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL S 2.DOUBLE WALL ❑ 90.NONE <br /> _.._-.- ....-______.- ............... ............. .......-...... ..-.............. ..I............. ..... -_.____. ............. ............. <br /> RISER PRIMARY CONTAINMENT ❑ 1.STEEL S 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify).. 4�j <br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL S 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): =1. <br /> ....... __'_-- -" ---___ . . ...._.... -_-_-- ..-...- <br /> FILL COMPONENTS INSTALLED ❑ I SPILL BUCKET ❑ 3 STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a<_ <br /> VII. UNDER DISPENSER CONTAINMENT (UDC) <br /> CONSTRUCTION TYPE ❑ I.SINGLE WALL S 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 4694 <br /> CONSTRUCTION MATERIAL ❑ I.STEEL S 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99-OTHER(Specify) 0696; <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSEDCURRFNT ❑ 6.ISOLATION 448. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: 1 certifyth thi system is compatible with the hazardous substance stored and that the information provided herein is true, <br /> accurate n i 1 m liance with legal <br /> requirements. <br /> APPLICANT SIGNATURE DATE 6/25/2010 470. <br /> APPLICANT NAME(print) I HALLOUM 4n- APPLICANTTITLE OWNER 4 <br /> 12 <br /> UPCF UST-B Rev.(122007)-1/2 www.unidocs.org <br />