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i UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST TYPE OF ACTION (Check one hem only. For a UST closure or removal,complete only this section and Secllons 1,11,111,,IV,and CC below) 430. op ® 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ T UST PERMANENT CLOSURE ON SITE ❑ 8,UST REMOVAL DATE UST PERMANENTLY CLOSED: 43N I 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) a. BUSINESS SITE ADDRESS 103. CITY Iw. 824 E. YOSEMITE AVE. MANl'ECA, CA. 95336 IL TANK DESCRIPTION- TANK IDN rtft Sz - TANK MANUFACTURER:==411ANK CONFIGURATION:THIS TANK IS 414. 390002314590505043 TRUSCO ® 1.ASTANU-ALONE TANK Complete one..ae fore.ch ❑ 2.ONE M A COMPARTMENTED UNIT mmp.nm.m in theanit. DATE UST SYSTEM INSTAI�IoW g405. TANK CAPACITY IN GALLONS 456 NUMBER OF COMPARTMENTS IN THE UNIT 457. 11L}99d S 12,000 1 III. TANK USE AND CONTENTS TANK USE ® In.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ le.AVIATION FUELING 419. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE preludm Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25231.5(o)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4590 CONTENTS PETROLEUM: ® la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS _ ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 4404. NON-PETROLEUM:❑ 7.USED OIL 0 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406. IN/. TANK CONSTRUCTION TYPE OF TANK _ ❑ I.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 0J9. PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. E9 7.STEEL+INTERNAL LINING [195.UNKNOWN [3 99. (Specify): 444= SECONDARY CONTAINMENT 0 1.STEEL ®3.FIBERGLASS [I6.EXTERIOR MEMBIN RANE LER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify); 4454. 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 ❑ I.SINGLE WALL ® 2.DOUBLE WALL ❑ 99.OTHER 460. SYSTEM TYPE ® I..PRESSURE ❑ 2,GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION D CCR§206(,)(3)] 458. PRIMARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ a.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 469• SECONDARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. ❑ 90.NONE 0 95.UNKNOWN ❑ 99.OTIIE•R(Syedfy)_ PIPING/TURBINE CONTAINMENT SUMP TYPE 14 I.SINGLE WALL. ❑ 2.DOUBLE WALT. ❑ 90.NONE 4644 VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT N 1.STEEL El 4.FIBERGLASS ❑ IO.RIGID PLASTIC ❑ 90.NONE ❑ 99,OTHER(Specify): 4640' 464e1. VENTSECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): gbgp; VR PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): q4M S_ VR SECONDARY CONTAINMENT ❑ LSTEEL [1 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE [3 99.OTHER(Specify): q�y�4jah VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 4641. RISER PRIMARY CONTAINMENT ® L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): g6q)I_ RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC N 90.NONE ❑ 99.OTHER(Specify): 4641. _ 46441__ FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ❑ 3.STRIKER PLATEtBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP -61.-u VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE _® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469.. CONSTRUCTION MATERIAL ❑ 1.STEEL ® 4.FIBERGLASS ❑ IO.R[Gm PLASTIC ❑ 99.OTHER(Spedty) 469.; VIII. CORROSIONPROTECTION STEEL COMPONENT PROTECHON ❑ 2.SACRIFICIAL ANODES ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IM APPLICAN-T- 010 I URE CERTIFICATION: I certify tbat is s stem is compatible with the hazardous substance stored and that the Information provided herein is true, accurate an n dl o imacp yvithAegalrreguirem6ats. APPLICANT SIGNATURE DATE 1/27/2011 400 APPLICANT NAME(print) R A HENRY 471' APPLICANT TITLE CUSTOMER SERVICE COORD. 4n. UPCF UST-111 Rev.(12/2007)-1/2 www.unidoes.org