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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One forth per UST) <br /> TYPE OF ACTION (Check one item only. Fora UST closure or removal,complete only this section and Sections Ill,111,IV,and IX below) 430. <br /> ® 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ S.CHANGE OF INFORMATION <br /> 6.TEMPORARY UST CLOSURE 1.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430- I DATE EXISTING UST DISCOVERED: 430 <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> Tracy Blvd Shell 136186 <br /> BUSINESS SITE ADDRESS CITY 1O4 <br /> 3725 Trac 109 Blvd Trac <br /> II. TANK DESCRIPTION <br /> TANK ID# 432• TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. <br /> I-Reguiar Owens Coming ® z.oNE IN A COOMPANE RTMENTED UNIT p-,m in Cowipkft one the an <br /> DATE UST SYSTEM INSTALLED 435_ TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. <br /> 5-22-1990 12,000 <br /> III. TANK USE AND CONTENTS <br /> TANK USE ® 1a.MOTOR VEHICLE FUELING (3 1b.MARINA FUELING ❑ Ic.AVIATION FUELING 439. <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(3&d.Used oil) ❑ 5.EMERGENCY GENERATOR FUEL IHSC 523231.5(c)) <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99,OTHER(Specify): 439a. <br /> CONTENTS PETROLEUM: ® In.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440. <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM( ify): 440& <br /> NON-PETROLEUM: 7.USED OIL L3 10.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUM(S ): 44%' <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN Mia. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER A44 <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(S i ): 444a. <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445_ <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 4458. <br /> OVERFILL PREVENTION ® 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT 1@ 3.FILL TUBE SHUT-OFF VALVE 452. <br /> ❑ 4.TANK MEETS REOUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ ".OTHER 4160 <br /> SYSTEM TYPE N 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR 42636(aX3)1 459• <br /> PRIMARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464& <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ &FLEXIBLE ❑ 10.RIGID PLASTIC 464b. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464&. <br /> PIPINGITURBINE CONTAINMENT SUMP TYPE ® I.SINGLE WALL 2.RUBLE WALL E390.NONE 464d. <br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4640. <br /> VENT SECONDARY CONTAINMENT [11.STEEL ® 4.FIBERGLASS E3 10.RIGID PLASTIC 1390.NONE ❑ 99.OTHER(Specify): Win. <br /> VR PRIMARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS 13l0.RIGID PLASTIC [390.NONE (3 OTHER(Specify): 04e <br /> VR SECONDARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS 1310.RIGID PLASTIC (390.NONE ❑ 99.OTHER(Specify): 4"hl_ <br /> VENT PIPING TRANSITION SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE ` <br /> RISER PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4 s: <br /> RISER SECONDARY CONTAINMENT [3I.STEEL ® 4.FIBERGLASS [3l0.RIGID PLASTIC 1390.NONE ❑ 99.OTHER(Specify): 4641. <br /> FILL COMPONENTS INSTALLED 0 1.SPILL BUCKET ® 3.STRIKER PLATEBOTTOM PROTECTOR ® C CONTAINMENT SUMP <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE <br /> 469bCONSTRUCTION MATERIAL (31.STEEL 1@ 4.FIBERGLASS [310.RIGID PLASTIC [3 ".OTHER(Specify) 469r- <br /> VIII. <br /> � <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ® 6.ISOLATION '48 <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION:I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, <br /> accurate,and in full compliance with legal r uiremeuts. <br /> APPLICANT SIGNATURE DATE 7/19/2010 470 <br /> APPLICANT NAME(print) Fadi a Al-Refaee 471. APPLICANT TITLE agent for Owner 472 <br /> UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org <br />