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F • 4 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK �� G �-� OPERATING PERMIT APPLICATION -TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11,Ill,IV,,and IX below) 430 ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4301 I DATE EXISTING UST DISCOVERED: 43ob I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) - �' t Q,' I BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3 CRLLC #2705446 BUSINESS SITE ADDRESS 103 1 CITY 104 1403 Country Club Blvd. Stockton, CA 95204 Ii: TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 -- / W 1 A STAND-ALONE IANK Complete one page for each ( C) C- C c;C ❑ 2.ONE IN A COMPARTMENIED UNIT compartment in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER F COMPARTMENTS IN THE UNIT 437 1/1/1991 9,728 III. TANK USE AND CONTENTS TANK USE ® la MOTOR VEHICLE FUELING ❑ Ib MARINA FUELING ❑ lc AVIATION FUELING 439 ❑ 3 CHEMICAL PRODUCT STORAGE ❑ 4 HAZARDOUS WAS TE(Includes Used Oil) ❑ 5 EMERGENCY GENERATOR FUEL[HSC§25281 5(c)] ❑ 6 OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OIHER(Specify): 439a _..... .- - -...__._....._...._.__ ._.._.._...._............ ......................_.. --..__._.........._._.._.._ _.........- ........_- - CONTENTS PETROLEUM: ❑ la REGULAR UNLEADED ❑ I MIDGRADE UNLEADED ❑ lb PREMIUM UNLEADED 440 ($ 3 DIESEL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440a NON-PETROLEUM:❑ 7 USEDOIL ❑ 10 ETHANOL ❑ 11.OTHER NON-PEIROLEUM(Specify): 440b -- IV. TANK CONSTRUCTION TYPE OF TANK ❑ I SINGLE WALL ® 2.DOUBLE WALL El 95_ NOW .UNKN 443 PRIMARY CONTAINMENT ❑ I STEEL ® 3 FIBERGLASS [__16 INTERNAL BLADDER _ ❑ 7 STEEL+INIERNALLININGQ 95 UNKNOWN [I99_OTHER(Specify): `tea - - SECONDARY I STEEL ®3 FIBERGLASS ❑ 6 EXTERIOR MEMBRANE LINER ❑ 7 JACKETED 445 ❑ 90.NONE El 95,UNKNOWN ❑99 OTHER(Specify): 445a OVERFILL PREVENTION ❑ I AUDIBLE&VISUAL ALARMS ❑ 2 BALL FLOAT 3 FILL.TUBE SHUT-OFF VALVE 452 ❑ 4.IANK MEEIS REQUIREMENTS FOR EXEMPTION FROM OVERFrLLPREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION N ❑ I.SINGLE WALL ® 2 DOUBLE WALL_ ❑ 99.OTHER 460 -._......._ _. _ ._-__ SYSTEM TYPE I PRESSURE [:12 GRAVITY Q 3 CONVENTIONAL SUCTION ❑ 4 SAFE SUCTION[23 CCR§2636(1)(3)) 158 PRIMARY CONTAINMENT ❑ 1 STEEL ® 4 FIBERGLASS 1--] 8 FLEXIBLE ❑ 10 RIGID PLASTIC 464 ❑ 90.NONE ❑ 95,UNKNOWN ❑ 99 OTHER(Specify): 4641 SECONDARY CONTAINMENT ❑ l STEEL. ® 4 FIBERGLASS ❑ 8 FLEXIBLE ❑ 10 RIGID PLASTIC a6ab ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c IN PIPG/TURBINE COIN NTAMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464a VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILI PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1 STEEL ® 4 FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90.NONE ❑ 99 OTHER(Specify): 4464eel _ --4f VENT SECONDARY CONTAINMENT ❑ 1 STEEL ❑ 4 FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90.NONE ❑ 99 OTHER(Specify): 4646 - .. ._._. . .. . ....._ _ . .. -. VR PRIMARY CONTAINMENT ❑ I STEEL ® 4.FIBERGLASS ❑ 10 RIGID PLASIIC [190 NONE ❑ 99 OIHER(Specify): 46481 VR SECONDARY CONTAINMENT ❑ 1 SIEEL ® 4 FIBERGLASS [1 10 RIGID PLASTIC [1 90 NONE ❑ 99 OTHER(Specify): 464hh .................._.... .._ .... .... ........ .... _. ..... __... .. .. ....._ ... __ ..__ _ .. ._ ...4641. VENT PIPING TRANSITION SUMP TYPE ❑ I SINGLE WALL ❑ 2 DOUBLE WALL ® 90 NONE RISER PRIMARY CONTAINMENT ® 1 STEEL El4.FIBERGLASS [3 10 RIGID PLASIIC [1 90 NONE [1 99 OTHER(Specify): 46aj1 RISER SECONDARYCONTAINMENT ❑ I STEEL ❑ 4 FIBERGLASS El 10 RIGID PLASTIC ® 90.NONE El 99 OTHER(Specify): 464kI FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR [14.CONTAINMENT SUMP 1511-c VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® I SINGLE WALL ❑ 2 DOUBLE WALL ❑ 3 NO DISPENSERS ❑ 90.NO .... ...9... CONSTRUCTION MATERIAL ❑ 1 STEEL ® 4 FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 99 OTHER(Specify) 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448 IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this s tem is mpatibl 'th the hazardous substance stored and that the information provided herein is true, accurate f lianc ith le r irements. APPLICANT SIGNATURE DATE [ / _© 470 APPLICANT NAME(print) Chuck . oftich 471 APPLICANT TITLE Manager of Compliance & Maint. 472 UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org __