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.7 UNIFIED PROGRAM CONSOLIDATED FORM c 7_ r &!> UNDERGROUND STORAGE TANK 1. y� , OPERATING PERMIT APPLICATION-TANK INFORMA O" (one Zrrm per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections I,A III,IV,and IX below) 430 r_11.NEW PERMIT El 3.RENEWAL PERMIT ® 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a 1 DATE EXISTING UST DISCOVERED: 4306. L 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# r 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. r� Unknown ® 1.A STAND-ALONE TANK Complete one page for each ❑ 2.ONE IN A COMPARTMENTED UNIT compartment in the unit. DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. 1/1/1991 9,728 r III. TANK USE AND CONTENTS TANK USE ® Ia.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 ❑ la MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 4ao. ® 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): 4406. IV. TANK CONSTRUCTION TYPE OF TANK l SINGLE WALL ®.2.DOUBLE WALL ❑ 95 UNKNOWN 443. _. ........ ....._. .... ... .... ._...... ........_..._.. ........._..... PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING C] 95 UNKNOWN ❑ 99 OTHER(Specify) 444a SECONDARY CONTAINMENT C] 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99 OTHER(Specify): 445a .............. 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.SINGLE WALL 02 DOUBLE WALL 99 OTHER 460, SYSTEM TYPE ® 1.PRESSURE ❑ 2 GRAVITY ❑_3 CONVENTIONAL SUCTION_ ❑ 4.SAFE SUCTIO11-"1N[23 CCR§2636(a)(3)] 458. ...... ...... 11.11 PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE 95.UNKNOWN ❑ 99 OTHER(Specify)_ 464a _ _ ........ ..__.. _.._._... _ ...___.__. SECONDARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. ❑ 90 NONE ❑ 95.UNKNOWN 0.99 OTHER(Specify)_ 464 11 c PIPING/TURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d. VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ ]0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464ej. ...._.... __._.... _......... VENT SECONDARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4648. VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99 OTHER(Specify): 464v1- ._.__...._ __...__.__.. _........ ._._.... ...._..__.... ..__...._.... ..._.._......__. 4641. _ -.. _..... (Specify):VR SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER S ecify): 464h1 .......-.....----....._.....-...._....._....._....._......_.....---.............._......_...._......-__...__..._......_.....---..._....__....__._... -..._.-...- - _..-__.._......__.._....._.....__.._.............._....._......._._..__...._...__..._......_......_...__...__.... VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUB*E WALL ® 90.NONE 464j._..... .......... ...... .......... RISER PRIMARY CONTAINMENT ® 1.STEEL ❑ 4,FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46411 ._..._...__._.�.�....-....- -.._..... _ ._....._....._..-..._-..-......__........_..__.._........._....._...._..._..__........_._...�. ______.-.. _.__._._....._...._-._........_...._......_...._.,. 464k. RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464kl. _....._..._..._...__..._..._.._._..._....._..-_. .___.._.._._____..-.__-_�._-.-_.__._.-__ _._.-._..__-_.___..._..._-.. .-----._-..._..._...---..__.-... ..---._..__..._.�__..___ FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET .STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ®_,1_SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a _.._._...-... _._._.._.._-._......_...--._-_...__....._......_....._._._... ._._._............_....._._...._...----...._..._._...- ----_.__..._.....-_..-_.__..... ..__....._....._....._..__....._..._.....................___._....._...._......._._._......_.... _...._........._...-- CONSTRUCTION MATERIAL ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696. 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 inM com lianc uirements. 470. APPLICANT SIGNATURE DATE05 APPLICANT NAME(print) Armen rtycblan 471 MkAPPLICANT TITLE California Compliance Manager 71 UPCF UST-B Rev.(12/2007)-1/2 www.unidoes.org