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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One 1404ehfiiT$016 TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 17,'1117, and iX below) 430 ® 1.NEW PERMIT N 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST RE NTAL HEALTH DATE UST PERMANENTLY CLOSED: N/A 4308 1 DATE EXISTING UST DISCOVERED: 4301, I. FACILITY INFORMATION FACILITY ID#(Agency Use OnlvJ I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 ki& FuE/- ve. TA 6520814 LIQ I BUSINESS SITE ADDRESS103 CITY 'I 2� 104 1490 SOUTH MAIN STREET MANTECA Nl 11 Iy1 1 1/ 11.TANK DESCRIPTION TANKID# 432 TANK MANUFACTURER TANK CONFIGURATION: THIS TANK IS 434 2B CONTAINMENT SOLUTIONS ❑ I.ASTAND-ALONE TANK ®2.ONE IN A COMPARTMENTED UNIT. Complete one pacefor each cohnanment in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 01/15/2017 12,000 2 Ill.TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ le.AVIATION FUELING 430 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Incudes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(1,)[ ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439. CONTENTS PETROLEUM: ❑ 1 a.REGULAR UNLEADED ❑ la MIDGRADE UNLEADED ❑ 1 b.PREMIUM UNLEADED 440 ® 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440. NON-PETROLEUM:❑ T USED OIL ❑ 10.ETHANOL ❑ 11,OTHER NON-PETROLEUM(Specify) 4401, IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ L STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL El 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 4,15a OVERFILL PREVENTION ® 1.AUDIBLE&VISUAL ALARMS [_12.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 El 1.SINGLE-WALLED ®2.DOUBLE-WALLED El 99,OTHER 460 SYSTEM TYPE El 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVEN"I tONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ &FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. SECONDARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 8.1 LEXIBLE ❑ 10.RIGID PLASTIC 4641, ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL IN 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641, 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 464f1 VR PALMARY CONTAINMENT ❑ LSTEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464g 4 VR SECONDARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS [1T [1l0.RIGID PLASIC 90.NONE ❑ 99.OTHER(Specify) 464h 4&ul 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) 464j 464'1 RISER SECONDARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k . 464 kl FILL COMPONENTS INSTALLED ISPILL BUCKET ® 3.STRIKER PLATFJBOTTOM PROTECTOR ® 4.CONTAINMENT SUMP 451e, VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ I.SINGLE WALL 8 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ L STEEL P9 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b< VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this CL§T system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full cogipfWce wit a al re uir ments. APPLICANT SIGNATURE DATE470- 1(1(5-1(6 APPLICANT NAME(prini) (ANNIE)GU ET SANDHU 4n_ APPLICANT TITLE 472_ PRfsro�rtr UPCF UST-B-1/2 Rev.(12/2007)