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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,ll,III,IV,and D(below) 430 ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ &'TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a 1 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ _ I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business-, 3 Tracy Blvd.Shell BUSINESS SITE ADDRESS 103 CITY 104 3725 N.Tracy Boulevard Trac H.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 1-Regular Q 1 r�� Owens Corning ®1.ASTAND-ALONE TANK ❑2.ONE IN A COMPARTMENTED UNIT. Complete one page for each compartment In the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 5-22-1990 12000 M.TANK USE AND CONTENTS TANK USE 0 la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ )c.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)l ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: N I a.REGULAR UNLEADED ❑ I c.MMGRADE UNLEADED ❑ 1 b.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8•PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USFD OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 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 ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ ).STEEL ®3•FIBERGLASS ❑ 6.EXTERIOR MEMBRANE,LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify)' ci : 445a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT ® 3•FILL TUBE SHUTOFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMP"I'ION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED N 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ® L PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR§2636(a)(3)j 458 PRIMARY CONTAINMENT ❑ ),STEEL ® 4,FIBERGLASS ❑ S.FLEXIBLE ❑ 10,RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(S ecify): 464e SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4640 PIPING/TURBINE CONTAINMENT SUMP TYPE ® I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT U 1.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 4640 464e1 VENT SECONDARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4,FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHBR(Specify) 4648 464SI VR SECONDARY CONTAINMENT I.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ® l.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 4641. RISER PRIMARY CONTAINMENT ].STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE Lj 99.OTHER(Specify) 4641 464'1 RISER SECONDARY CONTAINMENT IT_1_ST_E_EL__0 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE ❑ 99,OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATFBOTTOM PROTECTOR ID 4.CONTAINMENT SUMP 45la-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•RIGIDPLASTIC ❑ 99.OTHER(Specify) 469b-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ® 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICA ON: I certify that this UST system is compatible with the hazardous substance stored and that the information prov ii hersin is true,accurate, and in full compliance with legal requirements. 470. APPLICANT GNATURE DATE A71 . ....- 472. T NAME(print) APPLICANT. TLE i h ��•.,.:tea UPCF UST-B-114 Rev.(12/2007)