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Lr IFIED PROGRAM CONSOLIDATED FORW �J UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per S r� TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11,111,IV,and IX below) 430. ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL kN I DATE UST PERMANENTLY CLOSED: 430a I DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) - 1. BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. Marigold Shell BUSINESS SITE ADDRESS 103. 1 CITY 104. 6131 Pacific Avenue Stockton II. TANK DESCRIPTION TANK ID# 2432. TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 /ZZ 7 ® 1.A STAND-ALONE TANK Complete one page for each 3 Owens Corning ❑ 2.ONE INA COMPARTMENTED UNIT compartment in the unit. DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437 12,000 1 III. TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.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): 439s. ...................... .. . _ _ _ CONTENTS PETROLEUM: _.--...._0'la.REGULAR UNLEADED -❑ lc.MIDGRADE UNLEADED ❑ ib.PREMIUM UNLEADED 440. ® 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ...................---..-....._........ W . ----0 8.PETROLEUM BLEND FUEL0 9.OTHER PETROLEUM(Specify): 440x. . _.._.- __ .__.... NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION TYPE OF_TA_NK_ _ ❑_1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT- ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER -- - 444. \� ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444e. SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. _ _ ❑ 90.NONE„ W--0 95.UNKNOWN [199.OTHER(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 WALL ® 2.DOUBLE WALL [199.OTHER 460. ------- _._...-.._...._._._..._.. _._..........._._.. --._...._.........................................................._._.... _ _ .... _.....................__.-_...__._._................-....------- SYSTEM TYPE - - - 10 L PRESSURE [32:GRAVITY- ❑ 3 TIONAL SUCTION ❑ 4.SAFE SUCTI CONVENTIONAL 23 CCR§2636(a)(3)] --458. PRIMARY CONTAINMENT [:1L STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464. -.-._..........._..----._.-._---._..-_............._..._.._........_[1 90.NONE..-....... .0...95.UNKNOWN. -[1 99_OTHER(Specify): 464x. ..............__...__..._..._.. SECONDARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. -.-........................................ .---... - ----........................._._.__.._........._._.. ...................._............ ---..__.........-.......-.__...._._..... -...__....._. ........................ --.._.. PIPING/TURBINE CONTAINMENT SUMP TYPE ® I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE a6ad VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS ❑ ]0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 8464 -...-...--------...-_._...._...____-- _..._. _.. - VENT SECONDARY CONTAINMENT ❑ 1.STEEL (9 4.FIBERGLASS [110.RIGID PLASTIC [390.NONE [399.OTHER(Specify): 464n 4648. VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): -- ..... ..... . 464&1_... VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46441 VENT PIPING TRANSITION SUMP TYPE _ - ® L SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 464i 464]. RISER PRIMARY CONTAINMENT J9 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [:199.OTHER(Specify): 4641 ---._............... _..___._._ _._._ RISER SECONDARY CONTAINMENT ❑ L STEEL t9 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 446441 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENTS",-,, 45la-c. V I. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® I SINGLE WALL _ ❑ 2 DOUBLE WALL--0...3_NO DISPENSERS ❑ 90. 469a. _._-.�.... _............__... ..._.._._.. CONSTRUCTION MATERIAL ® I.STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC [199.OTHER(Specify) i` 4696. 469c. VIII. CORROSION PROTECTION y a STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 1 ^_,_ 448. IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information pro erein is true, accurate,and in full compliance with legal requirements. -,'> APPLICANT SIGNATURE DATE 8/24/2009 470. APPLICANT NAME(print) Hung Thanh Tran 471 APPLICANT TITLE Own r Operator 472, UPCF UST-B Rev.(12/2007)-1/2 www.unidoes.org