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x FIED PROGRAM CONSOLIDATED F r� UNDERGROUND STORAGE TANK (T form OPERATING PERMIT APPLICATION-TANK INFORMATION ne(Dunn per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 11 111 III,IV,and IX OW) 430 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATIO -7 / ❑ 6.TEMPORARY UST CLOSURE ❑ 7.EST PERMANENT CLOSURE ON SITE ® 8.EST REMOVAL C I Ztk- q v DATE UST PERMANENTLY CLOSED:unknown 430e DATE EXISTING UST DISCOVERED:unknown 6,430bOma, I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) T1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 San Joaquin County Human Services Agency Building BUSINESS SITE ADDRESS 103 CITY l04 145 South Sutter Street Stockton II.TANK DESCRIPTION TANK ID# unknown 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 uknown ❑ I.ASTAND-ALONE TANK Tda-51f UP [12.ONE M A COMPARTMENTED UNIT. Com late am paec for tach com anment in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 unknown unknown unknown III.TANK USE AND CONTENTS TANK USE Q la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE Q 4.HAZARDOUS WASTE(Includes U.ed Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC¢25291.5(c)I ❑ 6.OTHER GENERATOR FUEL ® 95.UNKNOWN ❑ 99.OTHER (Specify): 439. CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED Q Ic.MIDGRADE UNLEADED Q 1b.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): unknown 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): Mob IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ L STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ® 95.UNKNOWN Q 99.OTHER (Specify): 444. SECONDARY CONTAINMENT ❑ L STEEL ❑3.FIBERGLASS Q 6.EXTERIOR MEMBRANE LINER Q 7.JACKETED 445 ❑ 90.NONE ® 95.UNKNOWN ❑99.OTHER(S eci 4458 OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT Q 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-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR§2636(a)(ol 458 PRIMARY CONTAINMENT ❑ ].STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE Q 10.RIGID PLASTIC 4646 ❑ 90.NONE Q 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE Q 1.SINGLE WALL ❑ 2.DOUBLE WALL Q 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464" 464c1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 19.OTHER(Specify) 464f VR PRIMARY CONTAINMENT C1 1.STEEL El4.FIBERGLASS Q ]O.RIGID PLASTIC El90.NONE ❑ 99.OTHER(Specify) 464114648 4641 VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 46,IhI VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL Q 90.NONE 4641. RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RJGID PfASTIC Q 90.NONE ❑ 99.OTHER(Specify) 464j 4Mjl RISER SECONDARY CONTAINMENT Q L STEEL ❑ 4.FIBERGLASS Q 10,RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTARJMENT SUMP 451a-e VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. 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 Z 470. ( t'e.Ar /O APPLICANT NAME(print) 471. APPLICANT TITL472. �r�e -Fo UPCF UST-8-1/2 Rev.(12/2007)