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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK 1�J OPERATING PERMIT APPLICATION-TANK INFORMATION (one Torm per USTI TYPE OF ACTION (Check one Item only. For a UST closure or removal,complete only this section and Sections/,fi ffl,IV,and f.Yhelou) 430. ® 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: ON 1 DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID N(Agency Use Only) _ I. BUSINESS NAME(Same as FacliftyNana or DB -Dohtg Business As) 3. BUSINESS SITE ADDRESS 103. CITY lw. 824 E. YOSEMITE AVE. MANTECA, CA. 95336 II. TANK DESCRIPTION_ TANK IUfl - 0x. TANK MANUFACTURER 433. TANK CONFIGURATION:'1'HIS'I'ANK IS 434. 3 90 0023 14590505 045 TRUSCO ® 1•A STAND-ALONE TANK Cumviat.ane pane I.,..h ❑ 2.ONE INA COMPARTMENTED UNIT mmpaninent in the unit. DATE UST SYSTEM INSTALLED 435. TANK CAPACITY N GALLONS 436, NUMBER OF COMPARTMENTS IN THE UNIT 437. I�/f4194 S 3 G,000 t III. TANK USE ANDCONTENTS TANK USE ® In.MOTOR VEHICLE FUELING ❑ Ib.MARINAFUHLING ❑ Ic.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(In<ludar Usee Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§252n1.5(4)l ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN a 99.OTHER(Speci ): 439.. CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ® Ib.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS _ ❑ S.PEPROLEUM BLEND FULL ❑ 9.OTHER PEIROLELIM(Specify): 440a. NON-PETROLEUM:0 ?.USED OIL 10,eTHANOL ❑ Ii.OTHER NON-PETROLEUM S ecif : 44ob. IV. TANNK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL_® 2.DOUBLE WALL ❑ 95.UNKNOWN Oro. PRIMARY CONTAINMENT ❑ I.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. _ ® 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN 0_99 OTHER(Specify): 444• _ SECONDARY CONTAINMENT ❑ I.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE El 95.UNKNOWN ❑99,OTHER(Specify): 445.. OVERFILL PREVENTION ❑ I.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ® 3.FILL TUBE SHUT'-OFF VALVE 452. 4.TANK MEETS RE UIREML'N'I S FOR FXEMPT'ION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION _ _PIPING CONSTRUCTION ❑ I.SINGLE WALL ® 2.DOUBLE WALL ❑ 99.OTHER 460. SYSTEM TYPE _ ® 1.PRESSURE ❑ 2.GRAVITY ❑ J.CONVENTIONAL SUCTION__❑ 4.SAFE SUCTION[23 CCR$636. ) 458. PRIMARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE EI 95.UNKNOWN ❑ 99.OTHER(SpecifyI 464L SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10,RIGID PLASTIC 464b. CI 90.NONE ❑ 95.UNKNOWN _ _❑ 99.OTHER(Specify): 464a PIPINGITURBINE CONTAINMENT SUMP TYPE ® I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4616. VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL P-IP% PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ® I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46641. VENT SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): q4Nn: VR PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): g6ga�' VR SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464°h i. VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE !� 4m1' RISERPRIMARYCONTAINMENT ® I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): g66 RISER SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99,OTHER(Specify): 4,.1 FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ❑ 3.STRIKER PLATF/DOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a-a VII. UNDER DISPENSER CONTAINMENT(UDC) - CONSTRUCTION TYPE ® I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 4fi9n. CONSTRUCTION MATERIAL ❑ I.STEEL ® J.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) nsx. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES ❑ I,IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICA'T'ION: I certifythat I' T sy, tem is compatible with the hazardous substance stored and that the information provided herein is true, accurate,and 1 all ancewith lc al requirements. APPLICANT SIGNATU DATE I/27/20II 47a APPLICANT NAME(print) R00RY °71' APPLICANT TITLE CUSTOMER SERVICE COORD. UPCF UST-B Rev.(12/2007)-112 www.tinidoes.org