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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYP;OFACTIC N (Check one item only. For a UST closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 430. . MIT ❑ 3.RENEWAL PERMIT ® 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430& 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. CRLLC #2705446 BUSINESS SITE ADDRESS 103. CITY 104. 1403 Country Club Blvd. I Stockton II. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. I P l t /' ® 1.A STAND-ALONE TANK Complete one page for each 4 Unknown ❑ 2.ONE IN A COMPARTMENTED UNIT compartment in the emit. DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436, NUMBER)OF COMPARTMENTS IN THE UNIT 43T 1/1/1991 2,500 III. TANK USE AND CONTENTS 1 TANK USE ® la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.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: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440& NON-PETROLEUM:® 7 USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1 SINGLE WALL ® 2.DOUBLE WALL ❑ 95 UNKNOWN 443. ......... .. _.__._... ...._.......... _. ............. 444. PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER _.6N NE] 7.STEEL+INTERNAL LINING El 95.UNKNOWN ❑ 99.OTHER(Specify): 444a SECODARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(_P. ).i. S eci 445& . .. _ _ 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 ❑ 1.1.SINGLE WALL .DOUBLE WALL 0 99 OTHER 460. SYSTEM TYPE ❑ 1 PRESSURE GRAVITY 0...3 CONVENTIONAL_ SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(ax3)] _...... _._ ..._... PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS E] 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464& _.....__..._...._..._..._._._...._..-.__...._................._......_.. ..._... _......_..___....__....._....._....._.....- --..`..._....._....__..._..._._.._..._.... _...._....__..___-__ SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. ......_. ._........... PIPING/TURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL 0.NONE 4644. VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIP G CONSTRUCTION 464e. VENT PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464el. _.......-. __ ............_ ..... __.... VENT SECONDARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [199.OTHER(Specify): 464114 VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 4�i _... _....__._... ..........._ _..._. ....._ ... - ..._........... ___.._ _ _...._. . ....._.. - __.... _64_.. VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464hl. _....._.......__._...----....._....._...__-...._.__.._.............._............._...__..__...._......-............__.-.�....__..._.__.... ----_ ...._..._._..-----._..__..._... ...._.....__.._....._....._........_...._,............._...._....__......_...._..._.._....._.... VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE a6at. /�c.1, _....... .... _ RISER PRIMARY CONTAINMENT STEEL ❑ 4 FIBERGLASS ❑ 10 RIGID PLASTIC -�p0.NONE ❑ 99 OTHER(Specify):____ 464'1: RISER SECONDARY CONTAINMENT ❑ 1 STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE [1 99. (Specify):OTHER(Speci 6G4k. 464k1. FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 451ac. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ❑ 1 SINGLE WALL ❑ 2.DOUBLE WALL ® 3.NO DISPENSERS ❑ 90.NONE 469a _....._..._�.._..... .._...____.. _...... __....._.._.....__.._...._ .. 4696. CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4690 VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate and inj4I complianSg,!!!!!!:MMLrequirements. APPLICANT SIGNATURE DATE05 azo. APPLICANT NAME(print) Armen Mkrtychlan 471 APPLICANT TITLE California Compliance Manager 472 UPCF UST-B Rev.(12/2007)-1/2 www.unidoes.org