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UNIFIED PROGRAM CONSOLIDATED FORM l UNDERGROUND STORAGE TANKf/�� ,• OPERATING PERMIT APPLICATION-TANK INFORMATION (one form per v`r� TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11,111,IV,and IX below) 430. ❑ 1.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: 43011 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) s. CRLLC/76#5446 BUSINESS SITE ADDRESS 103. CITY 104. 1403 Country Club Blvd. Stockton H. TANK DESCRIPTION TANK ID# 432 r 432. TANK MANUFACTURER 433, TANK CONFIGURATION:THIS TANK IS 434. D l� `q I S' 1 ® 1.A STAND-ALONE TANK Complete one p page for each Unknown ❑ 2.ONE INA COMPARTMENTED UNIT compartment in the unit. DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437• -L Zl H/1991 2,500 III. TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING 1b.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 ❑ Ib.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS _.. ❑ 8 PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 44011 NON-PETROL EUM:® 7.USED OIL __........... . ....... .. ❑ 10.ETHANOL ._.._ ..._. ❑ 11.OTHER NON-PETROLEUMS eci 4406. ICV.i.TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 0 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_): 444x. --- - - SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify). 44511 ...._.. ......... .. ........ ... ..._.. . .__..... 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 E UIPMENT V 'PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1 SINGLE WALL ❑ 2.DOUBLE WALL ❑ 99 OTHER 460. .-. _ .. __ SYSTEM TYPE ❑ l PRESSURE ❑ 2 GRAVITY ❑ 3 CONVENTIONAL SUCTION 4SA SUO ❑ . FE SUCTION[23 CCR§2636(a)(3)] 458 -- - _ PRIMARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ...................---.._._........_....._.._--...................._._-_.-0 90.NONE - ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a. .................._........._._.._._._._....._.._._._...._.....__.._... ---...._.._......_._..__. ._ SECONDARY CONTAINMENT [11.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. .. _ ____ PIPING/1'URBINE CONTAINMENT SUMP TYPE _._........_....._._____....._._.__.._____.....___....___...__.._._._.. ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 464a. VI. VENT,VAPOR RECOVERY(VR)AND RISER'/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1 STEEL ® 4.FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90.NONE ❑ 99 OTHER(Specify} 446401 1..... .. .. .-.... ..... VENT SECONDARY CONTAINMENT ❑ 1 STEEL ® 4.FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90 NONE ❑ 99.OTHER(Specify): 4464f ......._ .. . .........._ ........_ . _ _.... _ _ VR PRIMARY CONTAINMENT ❑ 1 STEEL ❑ 4.FIBERGLASS ❑ ]0.RIGID PLASTIC ® 90.NONE ❑ 99.OTHERS eci 4648. _....-_ . --- . (Specify): _11-1.11464 1. VR SECONDARY CONTAINMENT ❑ I STEEL ❑ 4.FIBERGLASS ❑ 10 RIGID PLASTIC ® 90.NONE ❑ 99 OTHER(Specify): 46444; -_---- ---- _.._.. __.. .-_. .................._- --..... --..... --.... ................ ....... ........... . ._..... VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 464'. _ ... . ...._..... .. ............. _. .._......_. .._.. .....-- ..- .. ........ ....._._...... . ._ -........ __............... RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10 RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 444j 4 . RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 46464k' 441. FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUK 45111-C.- VII. UNDER DISPENSER CONTAINMENT (UDC) ,ri CONSTRUCTION TYPE -❑ 1 SINGLE WALL ❑ 2.DOUBLE WALL 469a. ........... ® 3 NO DISPENSERS ❑ 90 N E CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) ` 469c. 6. VIII., CORROSION PROTECTION m k 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 p ,Ided herein is true, accurate,and in full compliance with legal requirements. APPLICANT SIGNATURE CLK- DATE N,°^ 470. APPLICANT NAME(print) Allen FaaSS 471. APPLICANT TLE California Compliance Manager 472 UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org