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UNIFIED PROGRAM CONSOLIDATED FAVI 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 I,II,III,IV,and IX below) 430 X L NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE El8.UST REMOVAL 4106 Mc DATE UST PERMANENTLY CLOSED: DATE EXISTING UST DISCOVERED: I. FACILITY INFORMATION 1 FACILITY ID#(Agency Use Only) - - 3 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) Circle K#2701205 6 BUSINESS SITE ADDRESS 103 CITY 16470 Cambridge Drive Lathrop II.TANK DESCRIPTION TANK ID 4 412 TANK MANUFACTURER 033 TANK CONFIGURATION: THIS TANK IS 434 Unknown X 1.A STAND-ALONE TANK 1 ❑ 2.ONE M A COMPARTMENTED UNIT. M .om: for each com otcot in theuvit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 036 NUMBER OF COMPARTMENTS M THE UNIT 437 Unknown 10,000 1 III.TANK USE AND CONTENTS TANK USE z la MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc.AVIATION FUELING 039 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§252615(,)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439. CONTENTS PETROLEUM: X la REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ 1b.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 410a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL x 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL X 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): a44a SECONDARY CONTAINMENT ❑ 1.STEEL X 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED H5 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 445' OVERFILL PREVENTION 0 I.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT x 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION x I.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE x L PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(.X3)] 456 PRIMARY CONTAINMENT ❑ L STEEL X 4.FIBERGLASS ❑ &FLEXIBLE ❑ 10.RIGID PLASTIC 064 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(S ify): 464a SECONDARY CONTAINMENT ❑ L STEEL x 4.FIBERGLASS ❑ &FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464, PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER%FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ L STEEL x 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464, 4M4 l VENT SECONDARY CONTAINMENT ❑ 1.STEEL x 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 41 4f 464n VR PRIMARY CONTAINMENT 1.STEEL x 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4646 464 1 VR SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS 10.RIGID PLASTIC x 90.NONE ❑ 99.OTHER(Specify) 464h `tMhl VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL x 2.DOUBLE WALL ❑ 90.NONE 4641 RISER PRIMARY CONTAINMENT ❑ 1.STEEL x 4.FIBERGLASS L3 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464j 4641 RISER SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC x 90.NONE 99.OTHER(Specify) 464k 464kl FILL COMPONENTS INSTALLED x 1.SPILL BUCKET x 3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE x L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL x 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696-c 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 compliance with legal requirements. APPLICANT SIGNATURE DATE 420 �APPLICNAW(print) Duldnea Govan 491 APPLICANTTITLE Compliance Manager 472. UPCF UST-11-1/1 Rev.(12/2007)