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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 1,11,111,IV,and IX belo4v) n0_ ❑ 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: 4301 DATE EXISTING UST DISCOVERED: 4306. I. FACILITY INFORMATION FACILITY ID N(Agency Use Only) BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3, Tower Market# 886 BUSINESS SITE ADDRESS 103- CITY 104. 1434 W. Yosemite Ave. Manteca,CA 95337 II. TANK DESCRIPTION TANK ID N 432 TANK MANUFACTURER 433- TANK CONFIGURATION:THIS TANK IS 434. 886-Mid Modem Welding ® 1.ASTAND-ALONE TANK C.apl.lc..p18ef.,e�h ❑ 2.ONE IN A COMPARTMENTED UNIT -cal-uneens in ate unl[ DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436- NUMBER OF COMPARTMENTS IN THE UNIT 439. 1991 10,000 I III. TANK USE AND CONTENTS TANK USE M la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil ❑ S.EMERGENCY GENERATOR FUEL[HSC§25281 5(cy ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN _ _ ❑_99.OTHER(Specify)_ 43% CONTENTS PETROLEUM. ❑ Ia.REGULAR UNLEADED ® Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS [_B;PETROLEUM BLEND FUEL __❑ 9.OTHER PETROLEUM(SpecifZj_ 44oa. NON-PETROLEUM L] 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406. IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.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); 444.. SECONDARY CONTAINMENT ❑ I.STEEL [13+FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7,JACKETED 445- ❑ 90.NONE ❑ 95.UNKNOW_N ®99.OTHER(Specify): Steel Clad W/Fibereass reinforced plastic 445.. ____.__._-__ _________ _ ___ _________ OVERFILL PREVENTION ® I.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OPE VALVE 452 ❑ 4,TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 99.OTHER 460 .�-_--___.______.___...._____ _ ___._ _-- ____ ______..-_ .__-...._._ .___--__458_. SYSTEM TYPE ® 1.PRESSURE ❑ 2 GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4 SAFE SUCTION[v CCR§2636(x3)] _ PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 _ _ ❑ 90.NONE ❑ 95.UNKNOWN _____❑ 99.OTHER(Specify): 464.. SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ BF RIGID PLASTIC 4646 ❑ 90.NONE ___El95.UNKNOWN [199.OTHER(Scify): INRBpe464c _ PIPGlTUINE CONTAINMENT SUMP TYPE g I SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4ad. VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT [1I.STEEL [R 4.FIBERGLASS [110.RIGID PLASTIC [190.NONE ❑ 99.OTHER(Specify): 4 �' VENT SECONDARY CONTAINMENT ❑ 1 STEEL ❑ 4.FIBERGLASS ❑ 10. IIPLATIC ® 90.NONE ❑ 99+OTHER(Specify): 44M __ __ -_-.. . __ __,..__..__.---------------- ___ VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): I VR SECONDARY CONTAINMENT ❑ 1 STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99 OTHER(Specify): ' .......,_.--_....-.__-___--------------------------------. . ._.,.______ VENT PIPING TRANSITION SUMP TYPE [II SINGLE WALL El 2.DOUBLE WALL ® 90.NONE 4641 RISER PRIMARY CONTAINMENT E L STEEL ❑ I FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4643. __._.____----- 46,11, ._ 444iL.. RISER SECONDARY CONTAINMENT ❑ I STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): , FILL COMPONENTS INSTALLED ® L SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ® 4.CONTAINMENT SUMP iS1e' VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ❑ I.SINGLE WALL ® 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 4691. CONSTRUCTION MATERIAL ® t STEEL ❑ 1 FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 99.OTHER(Specify) +v„,� a69c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE S) ❑ I.IMPRESSED CURRENT ❑ 6.ISOLATION 'o "a. 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 coo Ilan with least re uirements. APPLICANT SIGNATURE �, DATE 11/1/2011 470. APPLICANT NAME(print) Paul CheVBller 4n. APPLICAM TITLE• 1VIffiittenance Manjg 472. 4 UPCF UST-B Rev.(12/2007)-112 www.unidocs.org