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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 430. ❑ 1.NEW PERMIT ® 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& 1 DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) - 1. BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. Food Mart Gasoline BUSINESS SITE ADDRESS 103• CITY 104. 2185 Fremont Street Stockton, CA. 95205 II. TANK DESCRIPTION TANK ID# ��r 432. TANK MANUFACTURER 433• TANK CONFIGURATION:THIS TANK IS 434. TAPS ( ❑ 1.A STAND-ALONE TANK Complete one page for each Modern Welding N 2.ONE IN A COMPARTMENTED UNIT compartmem in the unit DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436• NUMBER OF COMPARTMENTS IN THE UNIT 437• 2004 5,000 3 M. TANK USE AND CONTENTS TANK USE N la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ le.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) [1 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439x. CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ® lb.PREMIUM UNLEADED 440• ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440x. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL N 2.DOUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT N 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 441. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444x. SECONDARY CONTAINMENT ❑ 1.STEEL N 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445x. OVERFILL PREVENTION ® 1.AUDIBLE&VISUAL ALARMS N 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL N 2.DOUBLE WALL ❑ 99.OTHER 460. SYSTEM TYPE N 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(ax3)] 458. PRIMARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464• ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464x. SECONDARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c• PIPING/TURBINE CONTAINMENT SUMP TYPE N 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464& VI. VENT, VAPOR RECOVERY(VR) AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT N 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46 4c. VENT SECONDARY CONTAINMENT N 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4664 VR PRIMARY CONTAINMENT N 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 444$ VR SECONDARY CONTAINMENT' N 1.STEEL ❑ 4.FIBERGLASS [110.RIGID PLASTIC El 90.NONE El 99.OTHER(Specify): 4664h1 VENT PIPING TRANSITION SUMP TYPE N 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 44` RISER PRIMARY CONTAINMENT N 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4464j. RISER SECONDARY CONTAINMENT N 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464" FILL COMPONENTS INSTALLED N 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451ac. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE N 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a. CONSTRUCTION MATERIAL El1.STEEL El4.FIBERGLASS N 10.RIGID PLASTIC El99.OTHER(Specify) 4 . VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.[WRESSED CURRENT ❑ 6.ISOLATION �8• IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate and in full compliance with legal requirements. APPLICANT SIGNATURE DATE 2-- 470. APPLICANT NAME(print) Jogmder Lal 471. APPLICANT TITLE Operator/Owner 477- UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org