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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. Far a UST closure or removal, complete onfj, this section and Sections /,11,111,11! and I t below) 430. ❑ 1. NEW PERMIT ® 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE Q S. UST REMOVAL DATE. UST PERMANENTLY CLOSED: 430a 1 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID # (Agency Use Onl)) _ 1 BUSINESS NAME (Same as Facility Name or DBA - Doing Bushiess As) 3. Flyers #487 BUSINESS SITE ADDRESS 103. CITY ]w. 983 Moffat Blvd I Manteca II. TANK DESCRIPTION TANK ID # 432• TANK MANUFACTURER 433. TANK CONFIGURATION: THIS TANK IS 434 2 Modem Welding ❑ 1. A STAND-ALONE TANK Convicte ompage for each ® 2. ONE IN A COMPARTMENTED UNIT coff"rtrxnt in the unit. DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436• NUMBER OF COMPARTMENTS IN THE UNIT 437, 1998 8,000 2 III. TANK USE AND CONTENTS TANK USF N Ia. ;MOTOR VEIHCLE FUELING ❑ lb. 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): 439a. CONTENTS PETROLEUM: N In. REGULAR UNLEADED - ❑ le. MIDGRADE UNLEADED Q Ib. PRE,\HUM UNLEADFD 440 ❑ 3. DIESEL Q S. JET FUEL ❑ 6. AVIATION GAS ❑ S. PETROLEUM BLEND FUEL [19.OTHER PETROLEUM (Specify): 440a __ NON -PETROLEUM: ❑ 7. USED OIL [1-10. ETHANOL ❑ 11, OTHER NOAT-PETROLHUM (Specify): 440b. IV, TANK CONSTRUCTION TYPE OF TANK ❑ t. SINGI.F. WALL N 2, DOUBLE WAt.I. Q 45. UNKNOWN443. PRIMARY CONTAINMENT N L STEEL ❑ 3. FIBERGLASS Q 6. INTERNAL BLADDER 444• ❑ 7. STEEL r INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 444a _ SECONDARY CONTAINMENT ❑ 1. STEEL. ® 3. FIBERGLASS �❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445. ❑ 90. NONE [195. UNKNOWN ❑ 99. OTHER (Specify): sass. _ OVERFILL PREVENTION ❑ 1. AUDIBLE & VISUAL ALARMS ❑ 2. BALL FLOAT N 3. FILL TUBE SHUT-OFF VALVE 452• 4. TANK MEETS REQUIREMENTS FOR FXF.6IPTION FROM OVERFILL PREVENTION E UIPMENT V, PRODUCT / WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1. SINGLE WALL ® 2. DOUBLE. WALL❑ 99. OTHER 460' SYSTEM TYPE ® 1. PRESSURE - ❑ 2. GRAVITY - ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION 123 CCR §2636(a)(3)) 458. PRIMARY CONTAINMENT ❑ 1. STEEL - ® 4. FIBERGLASS 0 S. FLEXIBLE ❑ 10. RIGID PLASTIC 464 _464a ❑ 90. NONE [195.UNKNOWN C3 99. OTHER (Specify): SECONRY_DACONTAINMENT Q 1. STEEL N 4, FIBERGLASS Q S. FLEXIBLE ❑ 10. RIGID PLASTIC 464b ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specii & 464c. _ PIPING/TURBINE CONTAINMENT SUMP TYPE ® 1. SINGLE WALL- ^ ❑ 2. DOU13LE WALL ❑ 90. NONE a64a VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT Q 1, STEEL N 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 440e1.., VENT SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC N 90. NONE E) 99.OT peciry): 464171._ _ 664g. VR PRIMARY CONTAINMENT ❑ L STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLA , ', 9f1� Q� R ( city): 464 L VR SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS [110. RIG I 90;.NONE� ❑ 99:° Pvary): awhit, VENT PIPING TRANSITION SUMP TYPE ❑ L SINGLE WALL ❑ 2. DOUG E ': ® 90. NONE _ _ 4641. 464,. RISER PRIMARY CONTAINMENT ❑ 1. STEEL 4. FIBERGLASS ❑ 10. RIGID PLASTIC Q 90. N N ' 9j.OTHER (Specify): 464.1. RISER SECONDARY CONTAINMENT 131. STEEL El 4. FIBERGLASS ❑ 10. RIGID PLASTIC A' 99. OTHER (Specily): 464ki FILL COMPONFNTS INSTALLED N 1. SPILL BUCKET N 3. STRIKER PLATEBOTTOM PROTECTOR ❑ 4. CONT TENT SUMP 45la•e VII. UNDER DISPENSER CONT i" . L CONSTRUCTION_ TYPE N 1. SINGLE WALL ❑ 2. DO L _ S ❑ 90. NOME _..,_ 469a yLIZ CONSTRUCTION MATERIAL ❑ L STEEL Q 4. FIBERGLASS ❑ t0. fiiG1D PLASTIC 99.OTHFIt (Specify) Poly 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION 448 IX. APPLICANT SIGNATURE CERTIFICATION: i certify that tills UST systems is compatible with the hazardous substance stored and that (he Information provided herein is true, accurate id in fill compliance with le nl re it rements. APPL[CANTSIGNATURF DATE 10/4/2011 470 471. APPLICANT NAME (print) Alllanda Al)pelt APPLICANT TITLE Environmental Manager 432 (IPCF UST -B Rev. (12/2007) - 112 www.unidocs.org