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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPEOF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1.11,111,1V,and 1X 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: 43W 1 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ - 1• BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3 Tracy Blvd Shell 136186 BUSINESS SITE ADDRESS 103 CITY 104. 3725 Tracy Blvd Trac II. TANK DESC ON TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS434 3-Premium Owens Colvin ® 1.A STAND-ALONE TANK Ca"PWC oar pogo rw ad, Coming 2.ONE IN A COMPARTMENTED UNIT wmpattaxm in the,, DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436• NUMBER OF COMPARTMENTS IN THE UNIT 437, 5-22-1990 12,000 III. TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Ic.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(hwh do Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(e)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4393. CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ® Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Spwi ): 440 NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Slmi : 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ ".OTHER( ify): 444x. 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 ® 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS RE IREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION E UIPMENT Vs PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 99.OTHER 460, SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR 42636(x)(3)) 458. PRIMARY CONTAINMENT ❑ I.STEEL 13 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90,NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4Ma. SECONDARY CONTAINMENT ❑ L STEEL 13 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. PIPINGIfURBINE CONTAINMENT SUMP TYPE ® I.SINGLE WALL ❑ 2•DOUBLE WALL ❑ 90.NONE 464d, VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUICTION VENT PRIMARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4MO. VENT SECONDARY CONTAINMENT [31.STEEL ® 4.FIBERGLASS [310.RIGID PLASTIC ❑ 90.NONE [399.OTHER(Specify): 46644n VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464s VR SECONDARY CONTAINMENT ❑ L STEEL 1@ 4.FIBERGLASS 13 10.RIGID PLASTIC [390.NONE ❑ 99.OTHER(Specify): 4664b1_ VENT PIPING TRANSITION SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4&$' RISER PRIMARY CONTAINMENT ® L STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4 1. RISER SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 13 90.NONE ❑ 99.OTHER(Specify): 4664kI FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATEBOTTOM PROTECTOR 10 4.CONTAINMENT SUMP 451a-c VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 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 7/19/2010 470 APPLICANT NAME(print) Fadi Afa Al-Refaee 471 APPLICANT TITLE Agent for Owner 472 UPCF UST-B Rev.(122007)-12 www.unidoes.org