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IT- QVII( <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK 1 J� <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (one form per UST) �dd/��• <br /> TYPE OF ACTION (Check one Clem only. For a UST closure or removal,complete only this section and Sectlons(11,IB,M,and IX below) 430. <br /> ® 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ S.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430.. 1 DATE EXISTING UST DISCOVERED: 4301h. <br /> I. FACILITYINFORMATION <br /> FACILITY ID N(Agency Use Only) 1. <br /> BUSINESS NAME(Same as Faeili0t Name or DBA-Doirrg Business AS) 3. <br /> M X11, <br /> BUSINESS SITE ADDRESS 103. CITY IN. <br /> 824 E. YOSEMITE AVE. MANTECA, CA, 95336 <br /> IL TANK DESCRIPTION <br /> TANK IDN TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 43 <br /> 4� <br /> 39000 9050 TRUSCO IR I.ASTAND-ALONE TANK Con,piele one pMe r each <br /> 2.ONE IN A COMPARTMENTED UNIT eemp.rtnem in lh-W1. <br /> DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. <br /> 1.2LI994 6,000 1 <br /> TII. TANK USE AND-CONTENTS <br /> TANK USE ® Ia,MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439. <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.14AZARDOUS WASTE(Include,Used 010 ❑ 5.EMERGENCY GENERATOR FUEL IHSC 125291.5(c)1 <br /> ❑ C OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4394. <br /> CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ® to.MiDGRADE UNLEADED ❑ I b.PREMIUM UNLEADED 440. <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440,. <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ METHANOL <br /> ❑ 11.OTHER NON-PETROLEUM(Specify)! 440b. <br /> ' IV. TANK CONSTRUCTION " <br /> �. ' <br /> TYPEOFTANK _ ❑ 1.SINGLE WALL ® 2.DOUBLE WALL El 95.UNKNOWN 443. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. <br /> ® 7.STEEL,INTERNAL LINING ❑ 95.UNKNOWN_ ❑ 99.OTHER(Speciy): 444.. <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑_99.OTHER(Spcciy): 445.. <br /> OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ® 7.FILL TUBE SHUT-OpF VALVE 452. <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION E UIPAIENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONS'T'RUCTION ❑ 1.SINGLE WALL ID 2.DOUBLE WALL ❑ 99.OTHER 460. <br /> SYSTEM TYPE ® 1.PRESSURE ❑ 2,GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION IV CCR 12635(aXIII 458. <br /> PRIMARY CONTAINMENT ❑ L STEEL M 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 <br /> _ ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Speciy): 464,. <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. <br /> ❑ 90.NONE _ ❑ 95.UNKNOWN _ ❑ 99.OTHER(Specify): _ 4M, <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE R II.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE4644. <br /> VI.>VENT VAPOR RECOV_E_RX(VR) AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT R® I.STEEL _O 4.FIBERGLASS ❑ 10.RIGID PLASTIC O 90.NONE ❑ 99.OTHER(Specify): 461e�. <br /> VENT SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): gcanr <br /> VR PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ l0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): Jfi1' <br /> _ _ _ _ 464'.1. <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 444'ui: <br /> _VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL [12.DOUBLE WALL ® 90.NONE 9696 <br /> RISER PRIMARY CONTAINMENT E9 1.STEEL El 4.FIBERGLASS CI 10.RIGID PLASTIC [I90.NONE Elify) <br /> 99.OTHER(Spec : 4'1. <br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS_ff 10.RIGID PLASTIC O 90.NONE ❑ 99.OTHER(Specify): 46ak1. <br /> PILLCOMPONENTS INSTALLED 19 I.SPILL BUCKET ❑ 3.STRIKER PLATEIBOTTOM PROTECTOR [j 4.CON'fAINMEN]'SUMP 454-c <br /> VII. UNDER DISPENSER CONTAINMENT (UDC) <br /> CONSTRUCTION TYPE ® 1.SINGLE WALL _ ❑ 2.DOUBLE WALL ❑ 3.NODISPENSERS ❑ 90.NOM? 469,. <br /> CONSTRUCTION MATERIAL ❑ I.STEEL ® 4.FIBERGLASS Cl 10.RIGID PLASTIC ❑ 99.OTHER(Specify) nays. <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 4'16. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: 1 certify that 1 s ST system is compatible with the hazardous substance stored and that the information provided herein is true, <br /> accurate,an n it pliance.Athlexal requirements, <br /> APPLICANT SIGNATU DATE 1/27/2011 470 <br /> APPLICANT NAME(print) R DA HENRY 471' APPLICANT TITLE CUSTOMER SERVICE COORD. 4J2' <br /> UPCF UST-B Rev.(12/2007)-1/2 www unidocs.org <br />