Laserfiche WebLink
AM <br /> r' <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) <br /> TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,11,111,IV,and IX below) 430 <br /> ❑ 1.NEW PERMIT ❑ 3.RENEWAL.PERMIT X 5.CHANGE OF INFORMATION <br /> &TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL. <br /> DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 43�' <br /> FACILITY ID#(Agency Use On1}) I. FACILITY INFORMATION 1-' u <br /> BUSINESS NAME(Same as FACILITY NAME Or DHA-Doing Business As) 3 <br /> CRLLC#5447 <br /> 104 <br /> BUSINESS SITE ADDRESS 101 CITY <br /> 1469 E.Hammer Ln. Stockton <br /> II.TANK DESCRIPTION <br /> TANK ID 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TA\K IS 434 <br /> ■ 1.A STAND-ALONE TANK <br /> 7 � �� Unknown [12.ONE INACOMPARTMENTEDUNIT. <br /> Complete one page for each compa=cni in the unit <br /> DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 <br /> 3198 12,068 1 <br /> HL TANK USE AND CONTENTS <br /> TANK USE ® la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Ic.AVIATION FUELING 439 <br /> ❑ 3.CIIEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL IHSC§25281.5(c)) <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99,OTHER (Specify): 439a <br /> CONTENTS PETROLEUM: M la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 <br /> ❑ 3.DIESEL.. ❑ 5.JET FUEL. ❑ 6.AVIATION GAS <br /> [38.PETROLEUM BLEND FULL El9.OTHER PETROLEUM (Specify): 440a <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> El11.OTHER NON-PETROLEUM(Specify): 4aob <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WAIL ❑' 2.DOUBLE WALL ❑ 95.UNKNOWN 443 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL N 3.FIBERGLASS ❑ 6.INTERNAL.BLADDER 444 <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specifv): 444a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL M 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a <br /> OVERFILL.PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT IN 3.FILL TUBE SIIUT-OFF VALVE 452. <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑1.SINGLE-WALLED IN 2.DOUBLE-WALLED ❑99.OTHER 460 <br /> SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(ax3)1 458 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL It 4.FIBERGLASS ❑ 8 FLEXIBLE ❑ 10.RIGID PLASTIC 464 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464& <br /> SECONDARY CONTAINMENT ❑ 1.STEEL Ila 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify) 4600 <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE N 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d <br /> VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT L STEEL N 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e <br /> 464e1 <br /> VENT SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC § 90.NONE 99.OTHER(Specify) 464f <br /> 464n <br /> VR PRIMARY CONTAINMENT 0 L STEEL 0 4.FIBERGLASS 10,RIGID PLASTIC 90 NONE 99.OTHER(Specify) 4648 <br /> 464al <br /> VR SECONDARY CONTAINMENT 1.STEEL. 4,FIBERGLASS 10.RIGID PLASTIC ■ 90.NONE 99.OTHER(Specify) 464h <br /> 464h1 <br /> VENT PIPING TRANSITION SUMP TYPE 0 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 464' <br /> RISER PRIMARY CONTAINMENT N 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 <br /> 464'I <br /> RISER SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify) 464k <br /> 464k 1 <br /> FILL COMPONENTS INSTALLED ■ 1.SPILL BUCKET 0 3.STRIKER PLATEIBOTTOM PROTECTOR 4.CONTAINMENT SUMP 45la-c <br /> VII.UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ® 90.NONE 469a <br /> CONSTRUCTION MATERIAL ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTIIER(Specify) 469b-e <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448' <br /> IX. APPLICANT SIGNATURE �' <br /> CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided hereiwk ;n 14 accurate, <br /> and in full compliance with legal requirements. <br /> 4�0 <br /> APPLICANT SIGNATURE DATE " <br /> APPLICANT NAME(print) J71 472 <br /> APPLICANT TITLE <br /> Allen Faass Compliance <br /> (zu <br /> 17PCF UST-B-IR LL�01 <br /> (.�/ at4� g$ <br /> Rev.( 2807) <br /> Y <br />