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UNIFIED PROGRAM CONSOLIDATED FORM t UNDERGROUND STORAGE TANK 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 I,II,III,IV,and IX below) 430. ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT N 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430x. I DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION' FACILITY ID#(Agency Use Only) 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# T (;3 i�il jy/ 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. 1 Unknown N 1.A STAND-ALONE TANK Complete one page for each ❑ 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 437, 1/1/1991 9,728 III. TANK USE AND CONTENTS TANK USE N la.MOTOR VEHICLE 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): 439x. .. _ _ �. CONTENTS PETROLEUM: ® la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ 1b.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440a __..... - NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1 SINGLEWALL ® 2.DOUBLE WALL ❑ 95 UNKNOWN 443. PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. _.. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444& SECONDARY CONTAINMENT ❑ 1.STEEL N 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.N .. [199. 4 OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ® 3.FILL TUBE SHUT-OFF VALVE 451 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 1 SINGLE WALL ® 2.DOUBLE WALL 0 99 OTHER a6o. ..... SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY ❑ 3 CONVENTIONAL SUCTION_ ❑ 4.SAFE SUCTION t23 CCR§2636(a)(3)] 458. .... PRIMARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a. SECONDARY CONTAINMENT ❑ L STEEL N 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 46ab. ❑ 90.NONE ❑ 95,UNKNOWN ❑ 99.OTHER(Specify): 464c. - ....-.... .. .. ....... ... PIPING/TURBINE CONTAINMENT SUMP TYPE N 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE a64d. VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464el. ...... VENT SECONDARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS ❑ l0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4y1ll _...._..._ _. ..... ........ _...._.. ...._-_ .... .._...._.... _-.._............. _......_ ..... _..... ...__...__ VR PRIMARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464 g _...._......__. .....-_....._. . .-.........._... ......_....... _ ._._....... _._.__...__ _....._.... ...__....... _...._ .. .__._._ .. ...__.. .. _....._. _.._..... VR SECONDARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464hi _......._.._.._....._...._..-......._...--.__....._._..__._.__.....-..._....._....- ..__._....._...._......_.....-..._....._....._....._..............__....--...._......_....._.....__..... -..__._._._...__._-..._....._...__....._....._.. - ._....._....._....._.......__..._...._....._...... .. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL N 90.NONE 4�' ......_.._.. __......... __......... RISER PRIMARY CONTAINMENT N 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC E] 90.NONE ❑ 99.OTHER(Specify): 464i1. RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ ]0.RIGID PLASTIC N 90.NONE ❑ 99.OTHER(Specify): 464kl. .._.._...___.._.__....._... .._.._......__._....._....._ -_._ ... FILL COMPONENTS INSTALLED N 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR _ ❑ 4.CONTAINMENT SUMP 451a-c. VII. UNDERDISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE mN 1_SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469& _... ......_._..._...._._._.... ..... ----..._...- --- .- ......-.-- - . _..._...._1--.-_-____ ... .... ....._.._'_ .. _ ....._.-_. 4696. CONSTRUCTION MATERIAL ❑ 1.STEEL N 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 UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate and in com lianc uirements. APPLICANT SIGNATURE DATE470. 05 /'D APPLICANT NAME(print) Armen Mkrtychlan 471 APPLICANT TITLE California Compliance Manager 472 UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org