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ED PROGRAM CONSOLIDATED FOW UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. For a UST closure or remova4 complete only this section and Sections 1,Il,llT,lV and IX below) 430. ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT N 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ &UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION.1. FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. Gas Depot BUSINESS SITE ADDRESS 103. 1 CITY 104. 1330 E. Yosemite Ave. Manteca II TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433- TANK CONFIGURATION:THIS TANK IS 434• T-2 91 DW FRP ❑ 1.A STAND-ALONE TANK Complete one page for each ® 2.ONE IN A COMPARTMENTED UNIT -partment in the unit. DATE UST SYSTEM INSTALLED 435- TANK CAPACITY IN GALLONS 436• NUMBER OF COMPARTMENTS IN THE UNIT 437• 10,000 2 III. TANK USE AND CONTENTS TANK USE N 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: ❑ N.REGULAR UNLEADED ❑ Ic.MWGRADE UNLEADED ® lb.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 N 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): 444a SECONDARY CONTAINMENT ❑ 1.STEEL N 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN [199.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 UIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL N 2.DOUBLE WALL ❑ 99.OTHER460. SYSTEM TYPE N 1.PRESSURE El2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR§2636(a)(3)] -458• PRIMARY CONTAINMENT ❑ 1.STEEL N 4_FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99-OTHER(Specify): 464s. SECONDARY CONTAINMENT ❑ 1.STEEL N 4_FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(S fy): 464c. PIPING/TURBINE CONTAINMENT SUMP TYPE N 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 N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [1 99.OTHER(Specify): 464e. 464e1. VENT SECONDARY CONTAINMENT E] 1.STEEL [34.FIBERGLASS [I10.RIGIDPLASTIC N 90.NONE ❑ 99.OTHER(Specify): 464f].f VR PRIMARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS [110.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464&8' VR SECONDARY CONTAINMENT El1.STEEL [14.FIBERGLASS [110.RIGID PLASTIC N 90.NONE ❑ 99.OTHER(Specify): hh. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 4641. RISER PRIMARY CONTAINMENT N 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): X,j. RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE N 99.OTHER(Specify):10 miltape4464k. FILL COMPONENTS INSTALLED N I.SPILL BUCKET N 3.STRIKER PLATEIBOTTOM PROTECTOR N 4.CONTAINMENT SUMP 451a . VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ® 1_SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469&. CONSTRUCTION MATERIAL ❑ I.STEEL N 4_FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT N 6.ISOLATION 44s. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is c patible with the ha*dous substance stored and that the information pr6i4dell herein is true, accurate,and in full compliance wi I al ui APPLICANT SIGNATURE DATE 470. APPLICANT NAME(print) KeVln Hur 1' 471. APPLICANT rrLE 6wner 472. i " UPCF UST-B Rev.(12/2007)-1f2 ' www.unidoes.org