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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form perUST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections I,A 111,IV,and IX below) 430. ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ® 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430- 1 DATE EXISTING UST DISCOVERED: 4306. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) L BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. CRLLC/76 #5447 BUSINESS SITE ADDRESS 103. 1 CITY 104. 1469 E. Hammer Lane Stockton II. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. 4 Unknown ® 1.A STAND-ALONE TANK Complete one page for each ❑ 2.ONE IN A COMPARTMENTED UNIT compartment in the unit DATE UST SYSTEM INSTALLED 435• TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. 3/31/1998 10,563 III. TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ Ib.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): 439a. 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): 440a NON-PETROLEUM:❑ 7.USED OIL- ]0 - _____. ❑ .ETHANOL---._ ................. ❑ 11.OTHER NON-PETROLEUM(Specify): 4406. IV. TANK CONSTRUCTION TYPE OF TANK - ❑ 1.SINGLE WALL ® 2.DOUBLE WALL 0 95_UN[.NOWN 443. PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6 INTERNAL BLADDER_ - - 1.11, 444. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444. ------...__._._.....-----..-.._._._..........__._..__.._..----.._....._._...------.._._-.._._._..- - ....-- - ----------._._...- - --.-..__.__...__._.._._..._ -.._.. -. - SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER---(-p fl)'S eci 445. .-.._..._._......__......_......_...._.- - ----------- - ----- -- OVERFILL PREVENTION ❑ I.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 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 WALL ❑_2_DOUBLE WALL ❑ 99.OTHER 460. SYSTEM TYPE _ ❑ 1 PRESSURE ❑ 2 GRAVITY ❑ 3 CONVENTIONAL UCTION_L SUCTION ❑ 4 SAFE S [23 CCR§2636(a)(3)] 458. PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. -ECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. ❑ 90.NONE El95.UNKNOWN ❑ 99.OTHER(Specify): 464c. ---- ------------ ---------------- ----- -------- -.._......._.._........__._.-_..--.._._.-..------ ---- -- -- - -- --.. PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL [12.DOUBLE WALL 90.NONE 464d. VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER 464e. ( Peci ) 464el. VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS El 10.RIGID PLASTIC ❑ 90.NONE Elpec 99.OTHER(Si 464f. �) 464f1. VR PRIMARY CONTAINMENT ❑ L STEEL U 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHERS eci 4648' .. _ (Specify): 1. VR SECONDARY CONTAINMENT ❑ 1.STEEL [14.FIBERGLASS El 10.RIGID PLASTIC N 90.NONE 464h. ❑ 99.OTHER(Specify): 464h]. VENT PIPING TRANSITION SUMPTYPE 111.SINGLE WALL El 2.DOUBLE WALL ® 90.NONE 4641. ----------------- .. ---- --- - __ -...--- - - ---.._ _..... . .......-_. ................. -- ................. ---------------------._..._ RISER PRIMARY_CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 4643' RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS '❑ 10.RIGID PLASTIC -® 90.NONE ❑ 99.OTHER(Specify464k. FILL COMPONENTS INSTALLED _ '- _- ' ---- -- - ): 464k]. ^® 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR--❑ 4.CONTAINMENT SUMP 45la-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE 1_SINGLE WALL ❑ 2_DOUBLE WALL 469. i,3.NO DISPENSERS 90. _ ------.._._._...----------------- ---.._._.-.__.._..-.._. NONE CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ] 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 herein is true, accurate,and in full compliance with legal requirements. APPLICANT SIGNATURE _ DATE / 470. APPLICANT NAME(print) Allen FaaSS 471, APPLICANT TITLE California Compliance Manager 472. UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org