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RFGFIVELI UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK NOV 152016 OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) ado TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I�el{j,j 1 I �'AL HEAL I ® I.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE O �1j76},4t ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DEPARTMENT DATE UST PERMANENTLY CLOSED: N/A 4308 DATE EXISTING UST DISCOVERED: N/A 430n I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 11 - 1111 - 11 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 AG-5 F(Aa u✓c. tCA )It BUSINESS SITE ADDRESS103 CITY 114 1490 SOUTH MAIN STREET MANTECA )) �ll 1 If II.TANK DESCRIPTION TANKID# 432 TANK MANUFACTURER 433 TANS CONFIGURATION: THIS TANK IS 434 1 CONTAINMENT SOLUTIONS ® I.ASTAND-ALONE TANK ❑2.ONE IN A COMPARTMENTED UNIT, complete one pagefor each com artment in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 01/15/2017 20,000 1 III.TANK USE AND CONTENTS TANK USE [N ]a.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ 1c.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281 5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439. CONTENTS PETROLEUM: ® la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ Ib.PREMIUMI/NLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 4408 NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ L SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 Cl 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444. SECONDARY CONTAINMENT ❑ I.STEEL 913.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445. OVERFILL PREVENTION ® I.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT IN 3.FILL TUBE SHUT-OFF 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 ❑99.OTHER 460 SYSTEM TYPE KI L PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(a)(3)1 458 PRIMARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.0THER(Specify): t64a SECONDARY CONTAINMENT ❑ L STEEL El 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGrFURBINE CONTAINMENT SUMP TYPE ❑ I.SINGLE WALL ® 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I.STEEL M 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) A4c 464el VENT SECONDARY CONTAINMENT ❑ L STEEL M 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 4640 VR PRIMARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464g 464 I VR SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99,OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL IN 2.DOUBLE WALL ❑ 90.NONE -4 64, RISER PRIMARY CONTAINMENT ❑ I.STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT ❑ L STEEL IN 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4Mk 464kl FILL COMPONENTS INSTALLED A 1.SPILL BUCKET ® 3.STRIKER PLATEBOTTOM PROTECTOR ® 4.CONTAINMENT SUMP 45 1., VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL N 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL P9 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696, VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. 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 cojppliance with legal re irements. APPLICANT SIGNATURE DATE 470_ APPLICANT NAME(print) (ANN_1Ej%1159E_ETSANl6HU 411 APP ICANT TITLE 472_ 01pel/T UPCF LIST-B-1/2 Rev.(12/2007)