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UNIFIED PROGRAM CONSOLIDATED FORM ^�+ 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 1,II,117,IV,and IX below) 430. ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ® S.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE & [:1 8•UST REMOVAL DATE UST PERMANENTLY CLOSED: 430 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/76#5446 BUSINESS SITE ADDRESS 103. 1 CITY 104. 1403 Country Club Blvd. Stockton II. TANK DESCRIPTION TANK ID# � 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. 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. 1-11 -tff/1991 x;328- 0 III. TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ Ib.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 ❑ ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS 0 88_PETROLEUM BLEND FUEL ❑ 9 OTHER PETROLEUM(Specify): 4404 EUM:❑ 7.USED OIL------ 101.ETHANOL _ _......._..._.-,. ❑ . ❑ 11.OTHER NON-PETROLEUM(Specify): 4406. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2 DOUBLE WALL 95.UNKNOWN 443. PRIMARY CONTAINMENT I.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. D 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444a SECONDARY CONTAINMENT ❑ L STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 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.SINGLE WALL 0 2.DOUBLE WALL ❑ 99.OTHER 460. --------- ----._.._................_.......... .. . __........._._._...------------ SYSTEM TYPE ® l.PRESSURE ❑ 3.CONVENTIONAL SUCTION ❑ 4:.SAFE SUCTION[23 CCR§2636(a)(3) 458• ❑ 2.GRAVITY PRIMARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 __.__._............._..__.._........._--___....__.____ ❑ 90.NONE ❑ 95.UNKNOWN ❑_ 99.OTHER(Specify): 464& SECONDARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC -4646 - - ❑ 90.NONE El 95.UNKNOWN --❑-99.OTHER(Specify): 464c. PIPINGITURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE _ 464a. >VI. VENT,VAPOR RECOVERY(VR)AND RISER/FIL't PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90.NONE ❑ 99 OTHER(Specify): 464e. ..._-_-......_..__---_---.-__._-- -__--- __.-__ _._._._...._.._ ._._.__..__.............- _._..--- ._.._.__. 464e1. VENT SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4644 - -- ----------- --.... ---- _--- -- -- ------ -------..._... --------.._._....._..__...................--------- VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 464& ❑ 99.OTHER(Specify): 464 1. VR SECONDARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90 NONE ❑ 99 OTHER(Specify): 464h. - .. ____. _.....----- .. ..-- ---.._.._------- ------------- ... ._.____...... 464h1. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 46-41 .. -- ................... --- - ....- -- . ... _ RISER PRIMARY CONTAINMENT ® 1.STEEL [34.FIBERGLASS ❑ 10.RIGID PLASTIC [390.NONE [399.OTHER(Specify): 4641' 46411 RISER SECONDARY CONTAINMENT ❑ 1.STEEL- ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 4 FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM6441. OTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 4 64ki. 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. 469c. VIIL 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 full compliance with legal requirements. APPLICANT SIGNATURE DATE1-1511r,72-1111470. / / 470. APPLICANT NAME(print) Allen FaaSS 471. APPLICANT TITLE California Compliance Manag h 472' UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org