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03/02/2012 03:38 9252920074 GDF_SOLUTIONS FAX PAGE 12/15 a - Amok NIFiED PROGRAM CONSOLIDATED FWW <r UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(oneL` veF use TYPE:0F ACTION (Chmk one item only. For an UST pertnenent closure or removal,complete only this section end Sections 1,it III,IV.end IX below) 430 Q 1.NEW PERMIT' ❑ 3.MEWAL PERMIT ISI $.CHANGE OF INFORMATION ❑ 6.TEMPOP ARY UST CLOSURE I] 7.UST PEIUAANENT CLOSURE ON SITE S.UST REMOVAL DATE UST PERMANW-ITLY CLOSED: 4301 1 DATE EXISTING UST DISCOVERM. 4300 L FACILITY INFORMATION FACILITY ID#(Apmy UnDrily) _ - t BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 Country ClUb 75 BUSINESS SITE ADDRESS 5 CrrY toe 2575 Comoy Club Blvd. I Stockton H.TANK DES(MIIt'I'ION TANK Il)li q32 TANK MANUFACTURER 433 TANK COWiGURATION: THIS TANK IS 434 2-Pr b AO SMITH [3 L-A STAND-ALONE TANK �j 0 2.ONS IN A COMPARTMENTED UN77. COMM"$ON t f*f C"Can men In tlK vat. DATE UST SYSTEM INSTALLED 41S TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 01/01/2006 $000 2 III.TANK USE AND CONTENTS TANK USE IS Ia.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING [] le.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORACrE ❑ 4.HAZARDOUS WASTE a w.dm wed ow ❑ 5,EMERGENCY GMRATOR FUEL[MC§2329 15(c)] [36.OTHER GENERATOR FUEL L395.UNKNOWN [199.OTHER(Specify): 439. CONTENT'S Pl'sbUIUM; C) )$,REGULAR UNLEADED Cl la MCDGRADE UNLEADED R Ib.PREMIUM UNLEADED 400 ❑ 3.DIESEL ❑ $.JET VEML ❑ 6.AVIATION GAS C3 8.PETROL EUM SLENA FUEL ❑ 9,OTHER PETROLEUM Lsjnifft 4404 NON-PMOLEUM:❑ 7.USED OIL ❑ 10.ETHAMOL ❑ 11.OTIIER NON-PETROLEUM(5 440b IV. TANK CONSTRUCTION TYPEOFTANK ❑ 1.SINGLE WALL M 2.DOUBLE WALL a 95.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL M 3.FIBERGLASS Q 6.INTERNAL BLADDER 444 7,STEEL r INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER ( Y 444+ SECONDARY CONTAINMENT ❑ 1.STEEL N 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 415 ❑ 90.NONE ❑ 95.UNKNOWN ❑99,OTHER( 4% OVERFILL PREVOMON 13 1.AUDIBLE&VISUAL RM ALAS ❑ 2_BALL FLOAT r 3.FILL TUBE Slur-OFF VALVE 452. ❑ 4.TANK MEETS REQUMEiMENTS FOR E)MVIJPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRI JCTION PIPING CONSTRUCTION ffi,SINGLE-WALLED ®2-DOU9LC-WALL EU ❑99.OTFIER 460 SYSTEM TYPE ® 1,PRESSURE ❑ 2.GRAV'IT'Y 3.CONVENTIONAL SUCTION 0 4,SAFE SUCTION 127 CCR 2&W X3)I 41s PRIMARY CONTAINMENT ❑ L STEEL N 4.FIBERGLASS ❑ S.FLEXIBLE 0 10,RIGID PLASTIC 414 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99,97 A ( ); 164+ SECONDARY CONTAINMENT O I.S ria ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4640 Q 90,NON& ❑ 95,UNKNOWN ❑ 99,OTHER(Specify): 464c PIPINGITURBIN6 CONZA--*�SUMP TYPI11 ❑ 1.si Nau WALL ® 2,DOUBLE WALL ❑ 90.NONE 46M VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAR44ENT ).STEEL 13 4.FIBERGLASS13 !0.RIGID PLASTIC 13 90.NONE 464e99.OTHER(Speoify) 464et VENT SECONDARY CONTAINMENT I.STEL 4.FIMROL SC 10,RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464f *01 Vit PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10,RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 46411 4fti VR SECONDARY'CONTARJMENT In 1.STEEL 19 4.FIBERGLASS Ll 1o.RiGiA PLASTIC L3 90.NONF. ❑ 94,OTH g(Sp-iCy) 464h 4646f VWTPll?MTR,A'NSMON SUkV TYPE In 1,SINGLY,WAIL 0 2.DQUBLE W L 90.NONE 4". RMWPR&dAItYC0NTAR6fiWT 15 I.STEEL ❑ 4,FIBERGLASS U 10.RIGID PLASTIC L3 90,NOME U 99.OTHER(SpnifY) 4" RISER SECONDARY CONTAINMENT i,STEEL N 4.FIBERGLASS El 10.RIGID PLASTIC 0 96,NONE ❑ 99.OTHER(Specify) 464Y. 4a4u1 FILL COhU N ENTS INSTALLED 1.SPILL BUCK-7 C9 3,STRIKER FLATEMOTTOM PROTECTOR 10 4.COLNTAIWS1,,r SUW 4st+e VII.UNDER DISPE14UR CONTAPW14T((MC) CONSTRUCTION TYPE ❑ 1.SLNOLE WALL ® 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 464a CONSTRUCTION MATERIAL ❑ 1,STEEL ® 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 99.OTHER SPWr) 46901 VIII. CORROSION PROTF,MON STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED avail T 6.ISOLATION 449 DL APPLICAN'Y'SIGNATURE CERTIFICATION:.I certify tial this U system Is compatible with the hmrdous substance stored and that the Information pro .ded herein is true.accurate, and in full com li a with legal requirements. APPLICANT!? TU DATE470. APPLICANT NAME(print) A71' APPLICANT T ITL s7z Mita Ahmadi Dealer T)PCF UST-11-113 Rev.(12/2007)