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laa`l <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMITAPPLICATION-TANK INFORMATION (One form per UST) <br /> 'TYPE OF ACTION (Check one item only. Fora UST closure or removal,comPlete only this section and Sections 111.ill IP,and JX below) 430 <br /> ❑ I.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: Area DATE EXISTING UST DISCOVERED: 4396 <br /> I. FACILITY INFORMATION <br /> FACILITY ID p(.Agency Use Onty) t <br /> BUSINESS NAME(Some as Fnciho-Name or DBA-Doing Business As) 3 <br /> USA/Tesoro <br /> BUSINESS SITE ADDRESS 103 CI'T'Y Io4. <br /> 13975 E. Hiway 88 Lockeford <br /> H. TANK DESCRIPTION <br /> TANK ID p u± TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 <br /> j <br /> STIP ® 1,ASTAND-ALONE TANK Complweooe p.e.fw ec6 <br /> 2.ONE IN A COMPARTMENTED UNIT eompnnam in3M UNI. <br /> POONTENTS <br /> SYSTEM INSTALLED 43s TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 433 <br /> 1990 10,000 <br /> I <br /> III. TANK USE AND CONTENTS <br /> ® Is.MOTOR VEHICLE FUELING ❑ Ib.,MARINA FUELING ❑ Ic.AVIATION FUELING 439 <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE.(1-1w..u..4010 ❑ 5.EMERGENCY GENERATOR FUEL IHSC 125281 s(c)I <br /> ❑ 6.OTHER GENERATOR FUEL _ ❑ 95.UNKNOW_N ❑ 99.OTHER ISpeci[yl: ala.PETROLEUM: ® le.REGULAR UNLEADED ❑ Ic MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL 0.9 OTHER PETROLEUM(Spc,,fy <br /> M: I '--'-_-_ ___ <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.FTHANOI_ ----'-- <br /> ❑ 11.OTHER NON-PETROLEUM ISif o. Glob. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ I._SINGLE WALL ® 2,DOUBLE WALL ❑ 95.UNKNOWN ul. <br /> PRIMARY CONTAINMENT ® 1.STEEL ❑ 3.FIBERGLASS ❑ 6 INTERNAL BLADDER a4. <br /> ______ __ ❑ T.STEEL�INTERNAL LINING _ ❑ 95.UNKNOWN__❑ 99.OTHER(Specify). 4u.. <br /> SECONDARY CON AfNMEM ---- - ----- -- ---- <br /> ❑ I.STEEL ❑3.FIBERGLASS ❑ 6 EXTERIOR MEMBRANE LINER ® 9.JACKETED us <br /> ❑ 90.NONE ❑ 95 UNKNOWN ❑W.OTHER(Specify): us4 <br /> OVERFILL PREVENTION - <br /> ❑ I.AUDIBLE&V ISUAL ALARMS ❑ 2 BALL FLOAT ® 3.FILL TUBE SHUT-OFF VALVE 453 <br /> ❑ 4.TANK MEETS RE UIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 99.OTHER 4m <br /> SYSTEM TVPE _ __ ® 1 PRESSURE. ❑ GR4VRY_ ❑,3,CONVENTIONAL SUCTION ❑ d SAFE SUCTION CL1 Cc'a 4zsiN4N3N +53. <br /> PRIMARY COMMANEM ❑ I STFFL ® 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10 RIGID PLASTIC 4b4 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify)._ 4645 <br /> SECONDARY ® <br /> CONTAINMENT ❑ i.STEEL 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 <br /> _- __,. __ ❑ %.NONE 0 95 UNKNOWN ❑ 99.OTHER(Specifv): 444c. <br /> PIPNG/TURBINE COMANMEM SUMPTYPE ® LSINGLE WALL 0 DOUBLE WALL 090.NONE. 46se. <br /> VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ® I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC (:3W.NONE ❑ 99.OTHER(Specify): 194 <br /> V - ___.. <br /> VENT SECONDARY CONTAINMENT ❑ i.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 19 90.NONE ❑ 99.OTHER(Specify): 0 <br /> 464.1. <br /> VR PRIMARY COMANMEM ❑ I STEEL 6 4 FIBERGLASS ❑ RIGID GID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): =0 <br /> VR <br /> SECONDARY CONTAINMENT ❑ I S FEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ W.OTHER(Specify): 06a6 <br /> VENT PIPING TRANSITION SUMP TYPE _._.._ L _-....- - .............._-. _ +a1-. <br /> ❑ I SINGLE WALL ❑ 2.DOUBLE WALL ® 90 NONE <br /> RISER PRIMARY CONTAINMENT ® 1 STEEL ❑ 4 FIBFRG LASS ❑ lo.RIGID PLASTIC ❑ 90 NONE ❑ 99.OTHER(Specify): <br /> RISER SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99 OTHER(Specify) <br /> __ _ 4WSI <br /> _-___ - _-.__-___ <br /> FILL COMPONENTS MSTALLED ® I.SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION'TYPE _ ® 1 SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3_NO DISPENSERS ❑ 90.NONE 464 <br /> CONSTRUCTION MATERIAL ® 1 STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 446�',e <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ® 2 SACRIFICIAL ANODES) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 445. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: 1 certif-v that this UST system is compatible with the hazardous substance stored and that the information provided herein is true. <br /> aecuraI el to toll eom hance with legal requirements. <br /> APPLICANT SIGNATURE I S DATE 6/8/2009 4,9 <br /> K <br /> APPLICANT NAME(ji-B Sandy Edivards 471 APPLICANT TITLE Environmental Compliance 47' <br /> UPCF UST-B Rev.(12nM7')-1/2 www.uoidoes.org <br />