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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per us'r) 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 ❑ 1.NEW PERMIT [:13.RENEWAL PERMIT IM5.CIIANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.LIST PERMANENT CLOSURE ON SITZ: ❑ 8.UST REMOVAL. DATE UST PERMANENTLY CLOSED: 430° DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) t 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 ll.TANK DESCRIPTION TANK ID9,-I AC�) .'., �.7`� 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 0 1.A STAND-ALONE:TANK 4 Unknown ❑2.ONF IN A CO\mPARTNENTED UNIT. ,.m Iete one a e ror each com anment in the unit_ DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 3/96 10,563 III.TANK USE AND CONTENTS TANK USE 11 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§25291 5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic,MIDGRADF.UNLEADED ❑ Ib.PREMIUM UNLEADED 440 M 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8-PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ l0.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL. © 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL. IN 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95 UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ L STEEL E 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER(S ecify): 445a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL.ALARMS ❑ 2.BALL FLOAT E 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑I.SINGLE-WALLED M 2.DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE [M 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)) 458 PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL N 4,FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE M L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d V1.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL M 4.FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 0 10,RIGID PLASTIC 90.NONE: 99.OTHER(Specify) 464r 464n VR PRIMARY CONTAINMENT 1.STFEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4648 421 VR SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10 RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL 1090.NONE 4641, RISER PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 464'I RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATT7BOTTOM PROTECTOR 4.CONTAINMENT SUMP 451 a-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE e;. -A69a CONSTRUCTION MATERIAL ® I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99,OTHER(SpeciN) 4#9b-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT © 6.ISOLATION - 448 1X. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full compliance with legal requirements. APPLICANT SIGNATURE -r DATE y� i70 APPLICANT NAME(print) 471. APPLICANT TITLE Yn. Allen Faass Compliance t:PCF UST-13-1/2 Rev.(12/2007)