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D/ w4a UED PROGRAM CONSOLIDATED FORIS / 13 UNDERGROUND STORAGE TANK OPERA'T'ING PERMIT APPLICATION -TANK INFORMA'I*ON Onc form per UST-) fYPF.OI'ACTION E L NEW SLLE PERMIT ❑ 3.RENEWAL PERMIT E] 5.CHANGE OF INFORMATION 430 (Check only it-,only) 6.TEMPORARY SLIT;CLOSURE ❑ 7.PERMANENTLY CLOSED ON SLLE ❑ 8.TANK REMOVED DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 430b 1.RACIliITY'TNTOIiIVTATION FACILITY ID#(Agency Use Only) FA0000279 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 ESCALON MINI MART BUSINESS SITE ADDRESS 03 CITY 104 1097 YOSEMITE AVE ESCALON III.'rANKDESCRIPTION ' TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 ❑ 1.A STAND-ALONE TANK TA0507900 JOOR ❑X 2.ONE IN A COMPARTMENTED UNIT DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 05/15/1998 7,000 " 2 IIT.TANK I ISE AND CONTENTS TANK USE 0 la.MOTOR VEI IICLE FUEL ❑ ib.MARINA FUELING ❑ lc.AVIATION FUELING ❑ 3.CI IEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE ❑ 5.EMERGENCY GENERATOR FUEL ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Snecifv): CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑x Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): NON-PETROLEUM: ❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Snecifv): 440b [V.TANI 'CONS'tRiJCTION" ' . ..., 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 444a SECONDARY CONTAINMENT ❑ 1.STEEL ❑X 3.FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER ❑7.JACKETED 445 ❑98.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify) OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2 BALL FLOAT 1 3 FILL TUBE SHUT OFF VALVE 452 ❑4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT ��a{x8w'I'RODUGILWASTEPM! GTOft Ita 3 .. 1 PIPING CONSTRUCTION 1.SINGLE WALLED 2.DOUBLE-WALLED ❑ 99.OTHER" 460 SYSTEM TYPE 1.PRESSURE ❑2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 458 PRIMARY CONTAINMENT ❑ 1.STEEL ❑4.FIBERGLASS tW8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE [:195.UNKNOWN ❑ 99.OTHER 464a SECONDARY CONTAINMENT ❑ 1.STEEL ❑4.FIBERGLASSFLEXIBLE EI 10.RIGIDPLASTIC 464b E] 90.NONE ❑95.UNKNOWN ]�99.OTHER 464c PIPING/TURBINE CONI'AINNIENT SUMP TYPE I.SINGLE-WALLED ❑ 2.DOUBLE-WALLED ❑ 99.NONE 464d -•'VL VENT:VAPOR RECOVERY(YR),AND RISERIFII PIPE PIPING CONSTUCIION 3I . � r ;. d, f VEN L PIRMARY CON'T'AINMENT ❑ L S F L ❑X 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER 464e VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC jja7 90.NONE ❑ 99.OTHER 464f VR PIRMARY CONTAINMENT ❑ 1.STEEL MF 4.FIBERGLASS ❑ 12.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER 4648 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 12.RIGID PLASTIC 4W 90.NONE ❑ 99.OTHER 464h VENT PIPING TRANS...SUMP TYPE ❑ 1.SINGLE-WALLED ❑ 12.DOUBLE-WALLED 4W9.NONE 464' RISER PIRMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 12.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER 464j RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 12.RIGID PLASTIC ja 90.NONE ❑ 99.OTHER 464k FILL COMPONENTS INSTALLED 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c >VII:UNDER DISPENSER:CONTAINIVIENT(UDC) CONSTRUCTION TYPE 1.SINGLE-WALLED ❑ 2.DOUBLE-WALLED ❑ 3.NO DISPENSERS ❑90.NONE 469a CONTRUCTION MATERIAL ❑ 1.STEEL dW 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER r 469b-c Zft A-4 ft 0M P ` 4'VIII'CORROSION PROTEGTIOl e �;!I {'=.3 , „ 449 S'iEEL COMPONENT PROTECTION ❑ 2.SACRAFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 4 °l r IX APPI .0 SIG1Vi 1 I 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accura E nd in full compliance with legal requirements. �/ d J �.71I� �• APPLICANT SIGNATURE y�l�jF«t. DATE _ G �;''-'°� -7 470 APPLICANT NAME(print) BALWINDER SINGH 471 APPLICANT TITLE OWNER 472