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UNIFIED PROGRAM CONSOLIDAT EDFORM I 16 UNDERGROUND STORAGE TANK �n OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,ll,Ill,IV,and IX below) 470 ❑ I.NEW PERMIT ❑ 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE Z UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL L(419�b DATE UST PERMANENTLY CLOSED: 430' DATE EXISTING UST DISCOVERED: 10/4/1 I. FACILITY INFORMATION V� FACILITY ID#(Agency Use Only) - - :Ejj= BUSINESS NAME(Same m FACILITY NAME or DBA-Doing Business As) Caltrans BUSINESS SITE ADDRESS 0 P03 CITY Stockton 1O1 IL TANK DESCRIPTION TANK ID# ,�{�� M� (� 432 TANK MANUFACTURER 437 rT�AaNK CONFIGURATION: THIS TANK IS 474 ] Q(J1�] (/ / Unknown y1.ASfAND-ALONE TANK ❑2.ONE IN A COMPARTMENTED UNIT. C ee- fore ride emit DATE UST SYS�t1Fk1Mo.NSTALLED 435 TANK CAPACITY IN GALLONS LL�Oa S 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 IIL TANK USE AND CONTENTS 'TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE q 4.HAZARDOUS WASTE tt.onU,4d Din [15.EMERGENCY GENERATOR FUEL[HSC 425281.5(cH 439. ❑ 6.OTHER GENERATOR FUEL 95.UNKNOWN ❑ 99.OTHER (S 'fy): CONTENTS PETROLEUM: ❑ IR REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 449 ❑ 3.DIESEL ❑ 5.JE7 FUEL ❑ 6.AVdAT�QN GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM g i o omenta bboa NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ® H.OTHER NON-PETROLEUMS i : Unknown 4M3b IV. TANK CONSTRUCTION TYPEOFTANK L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444e SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMERANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN 99.OTHER(S i ): None ossa OVERFILL PREVENTION I.AUDIBLE VISUALALARMS 2. OAT 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT NONE V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED ❑2.DOUBLEWALLED ❑99.OTHER NONE '160 SYSTEM TYPE ❑ 1.PRESSURE M 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR 12636(a)(3)1 458 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Speeify): SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4W6 (n 90.NONE ❑ 95.UNKNOWN $99.OT14ER(Specifyg64v PIPINOITURBINE CONTAINMENT SUMP TYPE Ll 1.SINGLE WALL [12.DOUBLE WALL 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER)FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC E9 W.NONE 0 99.OTHER(Specify) 464e 464.1 VENT SECONDARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE99.OTHER(Speafy) '> 464Fl VR PRIMARY CONTAINN[E:NT ❑ 1.STEEL ❑ 4.F03ERGLASS 0 10.RIGID PLASTIC El 90.NONE El 99,OTHER(Specify) 464. VR SECONDARY CONTAINMENT 1.STEEL t FIBERGLASS C1 10.RIGID PLASTIC El 90.NONE 0 99.OTHER(Specify) A64h 464b1 VENT PIPING TRANSITION SUMP TYPE Q 1.SINGLE WALL Q 2.DOUBLE WALL 19 90.NONE RISER PRIMARY CONTAINMENT LI 1.STEEL U 4.FIBERGLASS U 10.RIGID PLASTIC W.NONE U W.OTHER(Specify) a6464jll RISER SECONDARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS U 10.RIGID PLASTIC E3 90,NONE 99.OTHER(Speufy) 463k 463kl FILL COMPONENTS INSTALLED -CFI-.SPILL BUCKET 0 3.STRIKER PLATE(BOTTOM PROTECTOR 4.CONTAINMENTSUMP UNK11OWN751cc VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ® L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469. CONSTRUCTION MATERIAL 13 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC LJ 99AHHER(S ) tG1b" VIIL 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 har9rdous substance stored and that the information provided herein is true,accurate, and in fu fiance with legal re uirement& 470 APPLICANT SIGNATURE DATE 10-17-13 APPLICANT NAME(print) 471. APPLICANT TITLE Director/Agent an Tim ane U PCF UST-B-112 Rev.(12/2007)