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n IFIED PROGRAM CONSOLIDATED FMM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (one form per UST) TYPE OF ACTION (Check one item only. For a UST closure or remora!, complete only this section and Sections I, n III, IV and LY below) 430. ❑ I NEW PERMIT ❑ 3. RENEWAL PERMIT ® S. CHANGE OF INFORMATION ❑ 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 430- DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID # (Agency Use Ordy) - - BUSINESS NAME (Same as Facility Name or DBA - Doing Business As) 3. Gas Depot BUSINESS SITE ADDRESS 103. 1330 E. Yosemite Ave. CITY 104. Manteca H. TANK DESCRIPTION TANK ID # 432• T-1 8% TANK MANUFACTURER 433. ©w FRP TANK CONFIGURATION: THIS TANK IS 434. ® 1. A STAND-ALONE TANK Complete ow page for each ❑ 2. ONE IN A COMPARTMENTED UNIT comparemeat is the unit. DATE UST SYSTEM INSTALLED 435• TANK CAPACITY IN GALLONS 436• 20,000 NUMBER OF COMPARTMENTS IN THE UNIT 437. 1 TANK USE AND CONTENTS TANK USE ® 1a MOTOR VEHICLE FUELING ❑ Ib. MARINA FUELING ❑ ic. AVIATION FUELING 439. ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (includes used Oil) ❑ S. EMERGENCY GENERATOR FUEL [HSC §25281.5(c)] ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439a. CONTENTS PETROLEUM: N la REGULAR UNLEADED ❑ 1c. MIDGRADE UNLEADED ❑ 1b. PREMIUM UNLEADED 440• ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (Specify): 440x. 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 ❑ L STEEL N 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): 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 E UIPMENT V. PRODUCT /WASTE PIPING CONSTRITCTION' PIPING CONSTRUCTION ❑ 1. SINGLE WALL N 2. DOUBLE WALL ❑ 99. OTHER 4W SYSTEM TYPE ® L PRESSURE ❑ 2_ GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION 123 CCA §2636(a)(3)] 458. PRIMARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464• ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99- OTHER (Sp-ify): 464a SECONDARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464b. ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464a PIPINGMURBINE CONTAINMENT SUMP TYPE ® 1. SINGLE WALL ❑ 2. DOUBLE WALL. ❑ 9o. NONE 4644. VI, VENT, VAPOR RECOVERY (VR) AND RISER / FII1L P'E PIPING COlYSTRUCTIQN VENT PRIMARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify):q�j: VENT SECONDARY CONTAINMENT ❑ 1. STEEL. ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ® 90. NONE ❑ 99.OTHER (Specify):4464 VR PRIMARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC [390. NONE ❑ 99.OTHER (Specify): 464 B VR SECONDARY CONTAINMENT ❑ L STEEL. ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ® 90. NONE ❑ 99. OTHER (Specify): g464 VENT PIPING TRANSITION SUMP TYPE ❑ 1. SINGLE WALL ❑ 2_ DOUBLE WALL ® 90. NONE 464'' RISER PRIMARY CONTAINMENT ® 1. STEEL [34. FIBERGLASS ❑ 10. RIGIDPLASTIC ❑ 9o. NONE ❑ 99. OTHER (Specify): q� is k. RISER SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS [110. RIGID PLASTIC 1390. NONE ® 99. OTHER (Specify): 10 mil 464k1. FILL COMPONENTS INSTALLED ® 1. SPILL BUCKET ® 3. STRIKER PLATE/BOTTOM PROTECTOR ® 4. CONTAINMENT SUMP 451 a -c. ..... VII. UNDER DISPENSER CONTAII�TMENT (UDC) CONSTRUCTION TYPE ® 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 469a. CONSTRUCTION MATERIAL ❑ 1. STEEL ® 4. FIBERGLASS El10. RIGID PLASTIC ❑ 99. OTHER (Specify) 4 VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT ® 6. ISOLATION 448• IX. APPLICANT SIGNATURE JST s em is mpatibie with the hazardous substances and th the information provided herein is true, CERTIFICATION: I certify that this t accurate, and in fu cum is APPLICANT SIGNATURE =71f / DATE 470. 471' APPLICANT NAME (print) gem APPLICANTTITZE Oynier 472. UPCF UST -B Rev. (12/2007) -1/2 www.unidocs.org