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UNHWO PROGRAM CONSOLIDATED FORM <br /> UNDR RGROU"STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (Ole form per UST) <br /> TYPE OF ACTION (Check one its-only. For a UST closure pr remova4 complete only this section and Section 4 tt;111,IV,and M below) 4N• <br /> Q I-NEW PERMIT & 3.RENEWAL PERMIT ❑ S.CHANGE OF INFORMATION <br /> ❑ 6_TEMPORARY LIST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE S.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 4302. 1 DATE MaSTING UST DISCOVERED' 430b. <br /> -- <br /> L FACXMITY INF'OR1tiMATION <br /> F ACILM-ID#(4gamy use <br /> BUSINESS NAME(Same as.P•acMOt Xame ort -Doing BBusinasAs) 3. <br /> BON)'ARE MARKET#3 5 <br /> BUSINESS SITE ADD1?85S 1a3. CITY 104. <br /> 15 E.GRANT'LINE RD. TRACY <br /> II. TANK XESCIti PTION <br /> TA14K ID# 432. TANX MANUPACllMX,Ti 4M• TANK,CONFIGURATION:THIS TANK IS 434• <br /> TA 0140403 MODERN WEMING ❑ 1.A STAND-ALONE TANK Conpkte oxu vast toe osch <br /> ❑ 2.ONETNA COMPARTME=UNIT 4ofi3�ur dra iR4Y <br /> DATE UST SYSTEM TNSTALLEb _ TANK CAPAM'I•Y 1N GALLONS 416- NUMBER OF C01%2ART&IENTS IN TTS L ITT 437. <br /> 3-1�19�8 12,QQ0 <br /> ' �:. TANK FTSE A11TD'�"ONTE�1i•'I`S <br /> T_WUSE ® 1aMOTORVEMC'LBFUMING ❑ '1b.MARSNAF0FLILvG ❑ lr.AVZATIONPUELING 449. <br /> ❑ 3.CHENECAL PRODUCT STOUrE ❑4.1.1AZARDOUS WASTE Owh de Umd Orly ❑ 5,EMIEROlSNC y GENERATOR FUEL(HSC¢252811RO) <br /> ❑ 6.OTEWR GENERATCR FUEL 0 95.IIt xNOWN ❑99.OT;MR(Specify): 429& <br /> CONTENTS FETROLEUM: L3 I&REGULARUNL.FADffiv ❑ Ic.MO?GRADEUNLEAI3ED ❑ lb,PR'MA CUUNLHADED 440. <br /> [1 3.DIESEL ❑ 5.M-FIFEMI, ❑ a AVIATION GAS <br /> ❑ 8.PETROLEUMEtENDFUEL ❑ 9,OTHER PSUOLEUM(Specify); 440$ <br /> NON-PETROLET9M 0 z USED OIL U 10.ETT AXQL <br /> ❑ I I.OTMR NON PSTROLSLtIvI S 4406. <br /> IV. 'SANK CUNSTRIICTTQN. <br /> TYPE OI+TANK ❑ I.SINGLE WALT, 2.DOU).LZ WALL ❑ 95.UNKNOw±z 443. <br /> PRLWAIZY CONTAINMI~"NT ® I.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. <br /> ❑ 7.STEEL+INTfu7NAL MENG ❑ 95.UNKNOWN ❑99.OTHAX(Sao" ): 444& <br /> SECONDARY CONTAINMENT' 0 1.STEEL ®3.MERGLASS E3 6 EXTERIO$1A EMBRANlr LINER ❑ 7,JACKETEd 445. <br /> ❑ 90.NONE L( 93.LwKNOwN ❑99.OTHER( ): 445x, <br /> OVERFLI.L PREVENTION M 1.A.UMLE Bc VMVAL ALARW ® 2.BALL FLOAT E7 3.FILL TUBE SHUT-OFF VALVE 452, <br /> 4.7AN,CCNMTS RS S FOR TLON FPZA vZ OVERFr L pRL;VEN CN EQ ll h <br /> VRODU.C' 'lTASTEIPTNG C )NSTIFCTIp1V <br /> PIPING CONSTRUMON ❑_1.SINGLE WALL 142.DOUBLg WALL ❑ 99.oTHER 450. <br /> SYSTEMTYPE 09 1.PRHSS n ❑2.GRA:yrry 1❑ 3.CONVENTIONAL SUCTION ❑4.SAFE SUCTION(23,CCR§206WM) ass. <br /> PRIMARY CONTAINMENT Q 1.swE 0 4,FIBER GLASS ❑ s.PImiBLE ❑ 10.RIGID P1 ASTIC 464. <br /> n 90.NONE ❑ 95.UNKNOWN 10 99.OTEM(Specify): 4642. <br /> SECONDAPY CONTAINMENT [] mgL "-@ 4.FiBE.°.GLASS ❑ S_FL' LE ❑ 10.RIGID PLASTIC 4646. <br /> _ a 9o.NON>; _ ❑ 95.uNKNowN ❑99.OTEER cify): 464c. <br /> PIPINGITUR.5WE CONTAINMENT SU.4P TYPE 0 1.SIN«lZ WALL ❑ 2.DOUBLE WALL ❑ 90.NONE <br /> V . VEN,T,VAPOR RECD ERY <br /> (VR).ANb`RISER/Prr>r kVE PIP! 1 G'CQ?1TSTRUC7i'I0N <br /> VENT PRIMARY CON`T'AINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIOMPLASTIC ❑ 90 NONE Q 99.OT1-1�9(specify): 464e1, <br /> VENT SECONDARY CONTADMIEEN7 ❑ L ST I, ®4.PmEaRGLAss ❑ 10.Riam PT.AsIm ❑ 9o.NONE ❑ 99.Oti13)lZ(Specify)! <br /> VR PRIMARY CONTAnw-ENT [� 1.ST51 T 0 A PISE RGLASS ❑ 10.RIGIDPL AST1C ❑ S0.NO ❑ 99.OTHER(Specify)- 4� <br /> VR SECONDARY CONTAINMENT © 1_STEEL ® 4.FmmaLASs Ci 10.luampLASTIC ❑ 90.NONE f] 99.OTIaR(Spcefy): 4 i <br /> VIEN'T PIPING TRANSITION SUMP TYPE 19 1.MNOLR WALL ❑ 2.DOUBLE WALL ❑ 90.NONE <br /> RISE?PRIMARY 2Y C01\I AIiVMEN I ® I.STEEL <br /> El 4,FIBERGLASS ❑ 10.RXGXD PLASTIC Q 9o.14ONE Q 99.OTHER(Specify): <br /> RISER SECONDARY CONTATNMPa ❑ 1:sTEEt. 0 4.F313ERGLASS ❑ 10.RIGID PI A..STIC ❑ 90.NONE ❑ 99.OTB'ER(Specify): u/) 464&!. <br /> rT[L COMPONENTS INSTALLED ® 1.SPII LBUCIBT ® S.STRIIC'f;RPLATE)BOTT01APROTECTOR, ® a CONTAMRZNT SUMP 451s-c. <br /> VII. UNDER.DISPENSER CUNTARQAMNT(M,C) <br /> CONSTRUCTION TYPE IN 1,MKOLE WALL ❑ 1 DOCWLE WALL ❑ 3.No D1sF&NSERS ❑ 40.NOS 469$ <br /> CONSTRUCTION MATERIAL ❑ I.STEEL ®4.FT3F�GLASS ❑ 10.RIGMPLASTIC ❑ 99.OTImM(Spot*) <br /> :, 4d9c. <br /> VIII+ CQRRUSION PRO0CTIOlq <br /> 3TE COMPONENT PROTECTION ❑2.SAC1uFICIAL ANOOP S) ❑ 4,IMfPRE9sPD CURRSNT ❑ ISOLATI 446. <br /> X. APPLIC.ANT 816NATURE <br /> CEItTIprmTION:T cer"y that Jw.s t7ST systcw IS 40mpitime with the Unadovs sgbsv..Iace stored and that the info provided herein is truer <br /> a---tP, in fall tom ce with led ems. a(r <br /> APPLICANTSIGNATURE -y DATT% <br /> 1211/2011 y��` 470 <br /> APPLICANT NAME(pxfut) RUS S MCLEOD 471. APPLICANT=Y- AREA DIRECTOR 472. <br /> LEG-3 Z10/600d EEL-1 SL95-EZT-8011 sasr.zdj@Iud .zoodeN-WOd3 9Z:9T TZ r-50-ZL <br />