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UNIFIED PROGRAM CONSOLIDATED FORINI UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANINFORMATION (011e forn3 per usT> K TYPF OF ACTION (Check one item only. Fora UST elosure or removal,conrple(e arly this section mid Sections 1,11,1/1,IK mid!l'belox) 430 © 1.NEW PERMIT 9 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7-UST PERMANENT CLOSURE ON SITE ❑ S.UST REMOVAL DATF:UST PERMANENTLY CLOSED: ON I DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use On1)) - 1 BUSINESS NAM E(Shane as Facility Arame or DBA-Doing Business As) 3' Flyers#487 BUSINESS SITE ADDRESS 103. 1 CITY 104. 983 Moffat Blvd Manteca II. TANK DESCRIPTION TANK ID# 432. 'TANK MANUFACTURER 433. Tf\NK CONFIGURATION:TIf IS TANK IS 434 2 Modern Welding ❑ I.A STAND-ALONE TANK Complete ompage foreach ® 2.ONE IN A COMPARTMENTED UNIT companment in the unit. DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. 1998 81000 2 III, TANI{USE AND CONTENTS TANK USI: N la.MOTOR VEHICLE FUELING ❑ ib.MARINA FUELING ❑ 1c.AVIATION FUELING 439. ❑ 3.CHELt1[CAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oi)) ❑ S.EMERGENCY GENERATOR FUEL[IISC§25291.5(c)) ❑ 6.OTHER GENMRATOR FUEL ❑ 95.UN'KNOWiNT ❑ 99.OTHER(Specify): 439% CONTENTS PETROLEUM: ® la.REGULAR UNLEADED ❑ Lc.MIDGRADE UNLEADED ❑ 1b.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440a NON-PETROLEUM:❑ 7.USED OIL Q 10.ETHANOL ❑ 11.OTHER NON-PETROL.F:UM(Specify): 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WAIL. ❑ 95.UNKNOWN _ 443. PRIMARY CONTAINMENT ®-1.STEEL ❑ 3.FIBERGLASS Q 6.INTERNAL BLADDER 444' ❑ 7.STEEL r INTERNAL__ LINING _❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444a SECONDARY CONTAINMENT ❑ I.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MFMBRANE LINER [17.JACKETED 445. [I90.NONF ❑ 95.UNK\OWN ❑99.OTHER(Specify): 4asa. OVERFILL PREVENTION ❑ 1.AUDIBLE C VISUAL ALARMS ❑ 2.BALL FLOAT ® 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK NIF.FTS REQUIREMENTS FOR EXEMPTION FROM OVERFILL.PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL ® 2.DOUBLE WALL_ (:I99.OTHER 460._ SYSTEM TYPE - _ N 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(21 CCR;2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL - ® 4.FIBERGLASS © S.FLEXIBLE r O 10.RIGID PLASTIC 464 [190.NONE ❑ 95.UNKNOWN C199.OTHER(Specify): 461a SECONDARY CONTATNNiEi\TT [11.STEEL. ® 4.FIBERGLASS ❑ S.FLEXIBLE [I10.RIGID PLASTIC 464b ❑ 90.NONE C1 95.UNKNOWN ❑ 99.OTHER(Specify): 464c.- PIPNG/TURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL _❑ 2.DOUBLE WALL ❑ 90.NONE 4Wd VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ®4.FIBERGLASS [I10.RIGID PLASTIC El90.NONE ❑ 99.OTHER(Specify): 46646. VENT SECONDARY CONTAINMENT ❑ I.STEEL. (:14.FIBERGLASS [110.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 4601 VR PRIMARY CONTAINMENT ❑ 1.STEEL. ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC -❑ 90.NONE ❑ 99.OTHER(Specify): ��g VR SECONDARY CONTAINMENT [1I.STFF.L ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464hh]. VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 464i. RISER PRIMARY CONTAINMENT' O I.STEEL 181 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.Orf HER(Specify): 464 l- RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): g y_j _...... ..._...-- -T4._,..... -- --- - -.._.....__ FILL COMPONEINiT'S INSLLED ® 1.SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la•c VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUC_T[ON TYPE ® L.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE _ 469a CONSTRUCTION MATERIAL ❑ I.STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC ® 99.OTHER(Specify)Poly y qb, VIII. CORROSION PROTECTION COMPONENTPROTECTION ❑ 2.SACRIFICIALANODE(S) ❑ a.IMPRESSED CURRENT ❑ 6.ISOLATION 449 IX. APPLICANT SIGNATURE CF,RTIFICATION: I certify that tills UST system Is compatible%lith the hazardous substance stored nud that the Information providedaherehl is true, accura(e 1d in full com Ilinnce with I al requirements. APPLICANT SIGNATURE DATE 10/4/2011 470 APPLICANT NANIE(print) Amanda Appelt 471. APPLICANT TITLE a�z Environmental Manager LIPCF UST-B Rev.(12/2007)-1/2 www.tini(locs.org I