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qW81 IFIED PROGRAM CONSOLIDATED F ^ 1' ) UNDERGROUND STORAGE TANK1 OPERATING PERMIT APPLICATION-TANK INFORMATIO`1V One fo m per UST) C TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,11,111,IV,and IX below) acccc`Mvo ® 1.NEW PERMIT ❑ 3.RENEWAL PERMIT El 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ® 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430. 1 DATE EXISTING UST DISCOVERED: 4306 L FACILITY INFORMATION FACILITY IDH(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 4 3 Walgreens BUSINESS SITE ADDRESS 103 CITY --1 Del Northeast corner of Farmington Rd and E Stockton Mariposa Rd II.TANK DESCRIPTION TANK IDH Unknown432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 Unknown ® I.ASTAND-ALONE TANK © ❑2.ONE M A COMPARTMENTED UNIT. Com tete one",age for each com anmeM in the unit. DATE UST SYS EM MST LED 435 1 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 Unknown 1000 Unknown M. TANK USE AND CONTENTS TANK USE IN la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Include.Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(,)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439. CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ 1b.PREMIUM UNLEADED 440 ® 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440, NON-PETROLEUM:I] 7.USED OIL ❑ 10.ETHANOL ❑ I1.OTHER NON-PETROLEUM S eci 4401, IV. TANK CONSTRUCTION TYPE OF TANK ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ® 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 4" ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER SECONDARY CONTAINMENT ❑ 1.STEEL [13. (S �' 444a ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ® 90.NONE ❑ 95.UNKNOWN ❑99.OTHEK(Specify: 445a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.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 ®1.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(.)(3)) 458 PRIMARY CONTAINMENT ® L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ I0.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): g64a SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b N 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): qbq� PIPINGl1'URBINE CONTABJMENT SUMP TYPE IN 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPORRECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 29 90.NONE ❑ 99.OTHER(Specify) 464e VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ q.FIBERGLASS ❑ 10.RIGID PLASTIC W.NONE ❑ 99.OTHER(Specify) 4464f VR PRIMARY CONTAINMENT ❑ 1.STEE464171 L ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99 OTHER(Specify) 4648 VK SECONBER DARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIGLASS LJ10.RIGID PLASTIC ® 90.N 4E El99.OTHER(Specify) 4 64h VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL 464h1 ❑ 2.DOUBLE WALL ® 90.NONE 4641. RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 1 90.NONE 0-99.OTHER(Specify) 464j RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4,FBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHRR(Specify) 464k FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET 4Mk1 ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451..c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL LJ 3.NO DISPENSERS ❑ 90.NONE 469. CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ q.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4691,-, VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION 2.SACK FICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. X. APPLICANT SIGNATURE CERTIFICATION: I rtify tha is T cyst . co 'ble with the hazardous substance stored and that the information provided herein is true,accurate, nd in full eo rth I e uirements. APPLICANT SIGNATURE DATE 10/20/2011 470, APPLICANT NAME(print) Frank POSE 491. APPLICANT TITLE Department Manager 472, UPCF UST-B-1/2 Rev.(122007)