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AOL FIED PROGRAM CONSOLIDATED F �+} n fl I UNDERGROUND STORAGE TANK / /�( 1r I� p 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 1,11,III,IV,and 1 w) / 479- ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATIO Izl D/lC )L ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ® 8.UST REMOVAL C DATE UST PERMANENTLY CLOSED:Unknown 4304 DATE EXISTING UST DISCOVERED:unknownza ) _I 4111,unknown /a) I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 San Joaquin Coun Human Services Agency Building BUSINESS SITE ADDRESS 193 CITY 1°a 145 South Sutter Street Stockton H.TANK DESCRIPTION TANK ID# unknown 432 TANKMANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 uknown ❑I.A STAND-ALONE TANK Q' El2.ONE M ACOMPARTMENTED UNIT.VV Com lee one •e for each com aunt in the unit. U TYST DAT SE INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 unknown unknown unknown III.TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEfIICLE FUELING ❑ Ib.MARINA FUELING ❑ le.AVIATION FUELING439 El 3.CHEMICAL PRODUCT STORAGE [14.HAZARDOUS WASTE(Includm Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(¢)] ❑ 6.OTHER GENERATOR FUEL ® 95.UNKNOWN ❑ 99.OTHER (SipcciLft 439a CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ IC.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): unknown 449a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ L SMGLE WALL ❑ 2.DOUBLE WALL ® 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER q4q ❑ 7.STEEL+INTERNAL LINING ® 95.UNKNOWN ❑ 99.OTHER (S eci 444a SECONDARY CONTAINMENT ❑ L STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ® 95.UNKNOWN ❑99.OTHER IS eci 445a OVERFILL PREVENTION ❑ I.AUDIBLE&VISUAL ALARMS ❑ 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-WALLED 112.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR§2636(.H3)] 458 PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHERS eciIy): 464. SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGlrURBINE CONTAINMENT SUMP TYPE LJ1.SINGLE WALL EI 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL E:] 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464, VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 464¢1 99.OTHER(Specify) 4Mf VR PRIMARY CONTAINMENT 46411 ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464g 464.1 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90,NONE ❑ 99.OTHER(Specify) 464h VENT PIPING T4Mhl RANSITION SUMP TYPE ❑ 1.SMGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 46,i. RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464] RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 464'1 99.OTHER(Specify) 464k 964k1 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATEBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER S cif) 46964 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 �7/ �hWaC( ' DATE /Z /O 470. APPLICANT NAME(print) 471. APPLICANT TITLET 1 473 ,]�r r Gc 1 UPCF UST-B-1/2 Rev.(12/200.7)