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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 1,IL III,IV,and IX below) 430 ❑ I.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑Q 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE:EXISTING UST DISCOVERED: 430b 1. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ _ S I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 CRLLC#5447 BUSINESS SITE ADDRESS 103 CITY 1044 1469E.Hammer Lane Stockton 11.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: Tests TANK IS 434 ❑ I.A STAND-ALONE TANK 3 / Unknown ❑2.0\1.-IN A COMPARTMENTED UNIT. Com lete one page for each compartment in the unit DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 3/98 10,563 Ill.TANK USE AND CONTENTS TANK USE Q I a.MOTOR VEHICLE FUELING ❑ lb.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): 43% CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 ❑ 3.DIESEL. ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL 9.OTHER PETROLEUM (Specify): Unleaded Plus NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALT. ® 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 ®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 0 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL.PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED ®2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ® I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§26364)(3)i 458 PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Spccify): 464, SECONDARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CON"rA1NMENT SUMP TYPE E 1.SINGLE WALL ❑ 2.13OUBLE WALL. ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT I.STEEL. 3.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464f 4641`1 VR PRIMARY CONTAINMF.N'T 0 I.STEEL N 4.FIBERGLASS 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 4648 4&4mi VR SECONDARY CONTAINMENT 0 L STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL. ❑ 2.DOUBLE WALL ® 90.NONE 4641. RISER PRIMARY CONTAINMENT ® L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 464'1 RISER SECONDARY CONTAINMENT L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED @0 1,SPILL BUCKET 3.STRIKER PLATUBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 0 I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE. 469a CONSTRUCTION MATERIAL 9 I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.0"I'HER(Specify) 4696-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT M 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 hereiMs true,accurate, and in full compliance with legal requirements. APPLICANT SIGNATURE DATE r� `'.- - 470 APPLICANT NAME(print) 471. APPLICANT T EITLE 472 ,_._, Allen Faass Compliance :( UPCF UST-B-1/2 Rev.(12/2007)