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a A C UNIFIED PROGRAM CONSOLIDATED FORM /�/ F� UNDERGROUND STORAGE TANK / s- 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,71,III,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: 430- 1 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. 1 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 III. TANK7SE AND CONTENTS TANK USE ® Ia.MOTOR VEHICLE FUELING ❑ Ib.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): 439% ......__.._._.....__...._.._..._.. --._...__...---------.._...------'-_-_--- --_ --'......................-..............................._._-............--................. ......_............_... -- CONTENTS PETROLEUM: ® la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ Ib.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.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443. -----... -.-....-- -- ...--'-...__.._.._.........._._........_..__._..................._._.._......---..........._.. .....-.._._..-......-...-----._._....-'-- -...--------......._._._._.._._. PRIMARY CONTAINMENT ❑ I.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. 0 7.STEEL+INTERNAL LINING -❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444a --- -- _._ _ ...... .. .---- --- SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify):_ 445a OVERFILL PREVENTION ❑ I.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 ❑ I.SINGLE WALL ® 2.DOUBLE WALL ❑ 99.OTHEREM TYPE 1 PRESSURE GRAVITY ❑ 460. SYST ® ❑ 2. _ 3.CONVENTIONAL SUCTION ❑ 4 SAFE SUCTION[z3 CCR§2636(a)(3)]....-- asa. PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS E38.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a _........_......_...._._.__......_..........._...... ------.._..-----...__... ---------..-.. ----- --'--._...................._.._..._..._..__......._.__..._....._--....-......_......---...._ --- . -- --.._-- SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. ---- -- --- -- ---._._...__...---._..-_---..........._................_.._..._...._...._._...._-.._._..- ----....._._.._.._._.. PIPING/TURBINE 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): g464. _....... ......_._.... .. __._... ...-..... .......-_. ._._.... .. ......... - _.-..... ... .. .......... VENT SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [1 99. (Specify): 4664f14ft VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4644g. - ....._. .------ ..- ----- ... ..._....._._ ...._..._. ---._..._ _._._ _.._..... VR SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464h. -..-.._..._..__..-._....._..-- ._........ .... --- _._..... ............ ... ........_ ._..... .._... VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 4641 _ .............._._._. . .........._ --._._.... ._.__._..... __.._. .. ......._. ... _............ _.. RISER PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): a4641. RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 4464. FILL COMPONENTS INSTALLED _ ® 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR --(] 4 CONTAINMENT SUMP 45la-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® 1 SINGLE WALL_ ❑ 2.DOUBLE WALL 0 3.NO DISPENSERS ❑ 90 NONE - 469a CONSTRUCTION MATERIAL ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c. VIII. 'CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES ❑ 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 SIGNATUREu�/ DATE ,(�j 470. APPLICANT NAME(print) Allen FaaSS 471. APPLICANT TITLE California Compliance Manager 472 UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org