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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK 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,IL IB,IV,and IX below) 430 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ S.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 0 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 6308 I DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 JIFFY LUBE#598 BUSINESS SITE ADDRESS l03CrrY 104 1130 N.MAIN ST. IMANTECA II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 ANK HOOVER CONTAINMENT INC. ®1.AST IN COMPAALONERTMENTED TME ❑2.ONE M e COMPARTMENTED them UNIT. Co 1818 once afor ead�ca in the wrt. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 1999 500 1 III.TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINAFUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE N 4.HAZARDOUS WASTE(includes Used oil ❑ 5.EMERGENCY GENERATOR FUEL IHSC§25281.5(8)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 446 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM $ i : 4408 NON-PETROLEUM:M 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 406b IV. TANK CONSTRUCTION TYPE OF TANK BI.SINGLE WALL 02.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ■ 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL [13.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 M 90.NONE ❑ 95.UNKNOWN ❑99.OTHER($ eci ): 445, OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-0FF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED ❑2.DOUBLE-WALLED E 99.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE M 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR§2636(, 3)] 458 PRIMARY CONTAINMENT N 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHERS ' 464, SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ HI RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN E 99.OTHER(Specify): 464. PIPINGITURBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 4Md VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ L$TEFL 4.FIBERGLASS ❑ 10.RIGID PLASTIC N 90.NONE ❑ 99.OTHER(Specify) 4608 46481 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify) 64n 44Fl VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify) 4608 46d'l VR SECONDARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 464h 469h1 VENT PNING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE W ALL 90.NONE a64i RISER PRIMARY CONTAINMENT LATEST, 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC N 90.NONE ❑ 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT ❑ LATEST, ❑ 4.FIBERGLASS ❑ Ill.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 464k FILL COMPONENTS INSTALLED ❑ L SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 4�-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ® 90.NONE 469. CONSTRUCTION MATERIAL ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(5 i 4696. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION Us, IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hacardous substance stored and that the information provided herein is true,accurate, and in full compliance with legal requirements. APPLICANT SIGNATURECr,a.Q G� DATE 470 APPLICANT NAME(print) 671' APPLICANTT LJE�VrJ 472' aa�jqphs UPCF UST-B-1/2 Rev.(12/1007)