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U ED PROGRAM CONSOLIDATED FORqP UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION -TANK INFORMATION (One form per UST) �D ITYPEOFACTION (Check one item only. For a UST closure or removal.complete only this section and Sections[,11.111,1V,and 1,1(below) 430 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ® 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE C3 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4303 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID 0(Agency Use Only) B ,Name or DBA-Doing Business As) 3 esoro/Shell 68153 oib Nawe /} QAK SqATazN $X5153 INw q'AW SINESS SITE AD 103 1 CITY 104 2448 W. Kettleman Lane Lodi II. TANK DESCRIPTION TANK ID 0 432. TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 At 5 R o `180 Owens Corning ❑ 2.ONE N A COMPARTMENTED UNIT compan one page for each p3rtmem in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 1989 10,000 1 III. TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil ❑ 5.EMERGENCY GENERATOR FUEL 1HSC¢25281 5(,)1 _ _ _❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify). 4393 CONT . EN_TS PETROLEUM: ® la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ 1b.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5 JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL 0_9.OTHER PETROLEUM(Specify)_- 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(S i ): 440b IV. TANK CONSTRUCTION TYPE OF TANK _ ❑ I.SINGLE WALL ® 2.DOUBLE WALL [395.UNKNOWN 443 PRIMARY CONTAINMENT ❑ I-STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER - 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4443 SECONDARY CONTAINMENT ❑ I.STEEL ®3.FIBERGLASS ❑ 6 EXTERIOR MEMBRANE LINER ® 7.JACKETED 445 __ ❑ 90.NONE ❑ 9_5.UNKNOWN ❑99.OTHER(Specify): 445& OVERFILL PREVENTION ❑ I AUDIBLE&VISUAL ALARMS ❑ _ BALL FLOAT ® 3.FILL TUBE SHUT-OFF VALVE - 452. ❑ 4.TANK MEETS RE UIREMEN*rS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1 SINGLE WALL ® 2 DOUBLE WALL ❑ 99,OTHER 460 SYSTEM TYPEr__ - ® L PRESSURE [:1 2. 23(GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4 SAFE SUCTION CCR g2636(a 3) - 458 PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10 RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10 RIGID PLASTIC 4646. _❑_ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGlTURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2 DOUBLE WALL ❑ 90.NONE VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMEN'r ❑ 1.STEEL ® 4.FIBERGLASS [310.RIGID PLASTIC ❑ 90.NONE [199.OTHER(Specify): 4664e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL [14.FIBERGLASS [310.RIGID PLASTIC ® 90NONE ❑ 99.OTHER(Specify): 464 t VR PRIMARY CONTAINMENT - ❑ 1.STEEL ® 4,FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 446448 VR SECONDARY CONTAINMENT [IL STEEL ❑ 4.FIBERGLASS [310.RIGID PLASTIC ® 90.NONE ❑ 99,OTHER(Specify): 464644h VENT PIPING TRANSITION SUMP TYPE _ ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 464' RISER PRIMARY CONTAINMENT ® L STEEL [34.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [399.OTHER(Specify): 4Wij RISER SECONDARY CONTAINMENT ❑ L STEEL [34.FIBERGLASS [110.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 466kk. FILL COMPONENTS INSTALLED - ® l SPILL BUCKET ® 3 STRIKER PLATEIBOTTOM PROTECTOR - ® 4.CONTAINMENT SUMP 4513c VII. UNDER DISPENSER CONTAINMENT (UDC) _CONSTRUCTION TYPE_ _ ® I SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a - _...----- -- 4606 CONSTRUCTION MATERIAL ❑ I STEEL ❑ 4.FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 99.OTHER(Specify) 464c VIII. CORROSION PROTECTION ` STEEL COMPONENT PROTECTION ❑ 2 SACRIFICIAL ANODES) ❑ 4 IMPRESSED CURRENT ® 6.ISOLATION 448 IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate,and in full com liance with legal requirements. APPLICANT SIGNATURE . o „f s DATE 1/13/2011 47� APPLICANT NAME(print) Sandy Edwards w~� 471 APPLICANT TITLE Environmental Compliance 472 Lj UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org