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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,11,111,IV,and IX below) 430 ❑ I.NEW PERMIT ❑ 3.RENEWAL.PERMIT [j 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE. ❑ 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430s, 1 DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 CRLLC#5447 BUSINESS SITE ADDRESS 103 CITY 104 1469 E.Hammer Lane Stockton II.TANK DESCRIPTION TANK ID# -4 u 7 432 TANK MANUFACTURER 433 TANK CONFIGURA'T'ION: THIS TANK IS 434 HI.A STAND-ALONE TANK 2 Unknown El2.ONE IN A COMPARTMENTED UNIT Complete one p.Lge for each com anent in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 416 NUMBER OF COMPARTMENTS IN THE UNIT 437 3198 10,563 Ill.TANK USE AND CONTENTS TANK USE N la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CIIEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5 EMERGENCY GENERATOR FUEL[HSC§25281.5(c)I ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTIIER (Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADFsD ® 1 b.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 ❑ I0.ETIIANOL ❑ 1 1.OTHER NON-PETROLEUM(S eci ): 44ob IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL. M 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 E 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 SFIUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WAILED ®2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 9 L PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(a)(3)) 458 PRIMARY CONTAINMENT ❑ 1.STEEL ® 4_FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): "bop SECONDARY CONTAINMENT ❑ 1 STEEL, IN 4 FIBERGLASS ❑ 8 FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4646 PIPING/TURBINE CONTAINMENT SUMP TYPE ® 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. M 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT L STEEL 4.FIBERGLASS 10.RIGID PLASTIC ■ 90.NONE; 99.OTHER(Specify) 464f 4641 VR PRIMARY CONTAINMENT L STEEL @1 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4648 464 1 VR SECONDARY CONTAINMENT L STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 99,OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 0 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE: 4641. RISER PRIMARY CONTAINMENT ® I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4631 464'I RISER SECONDARY CONTAINMENT ❑ 1.STEEL. ❑ 4.FIBERGLASS ❑ 10 RIGID PLASTIC 0 90 NONE 99,OTHER(Specify) 464k 464k FILL COMPONENTS INSTALLED L SPILL BUCKET 3.STRIKER PLATFIBOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 451a-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE © 1.SINGLE WALL ❑ 2.DOUBLE WALL. ❑ 3.NO DISPENSERS ❑ 90.NONE 46% CONSTRUCTION MATERIAL ® L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) by ti VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ® 6.ISOLATION e. 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, ."u te, and in full compliance with legal requirements. APPLICANT SIGNATURE DATE . LL)43o, APPLICANT NAME(print) 471 APPLICANT TITLE 472 Allen Faass Compliance *fir UPCF UST-B-1/2 Rev.(12/2007)