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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,II,III,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: 4308 1 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID tl(Agency Use Only) _ I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 Tracy Blvd. Shell BUSINESS SITE ADDRESS 103 1 CITY 104 3725 N.Tracy Boulevard Trac H.TANK DESCRIPTION TANK ID It 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 2-Plus �A Q RLI r 0 Owens Corning ®].ASTAND-AI.ONP,TANK [12,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 III.TANK USE AND CONTENTS TANK USE ® Ia.MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)I ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ I a.REGULAR UNLEADED ® 1 c.MIDGRADE UNLEADED ❑ I b.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 ❑ 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): 4448 SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER(S cify): 4458 OVERFILL PREVENTION I.AUDIBLE&VISUAL ALARMS U 2.BALL FLOAT N 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-WALLED ®2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ® I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ 1,STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Speci ): 464a SECONDARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PEPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ L STEEL 19 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99,OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC D 90.NONE 99.OTHER(Specify) 4646 464g] VR SECONDARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC D 90.NONE 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE 0 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT N I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE Lj 99.OTHER(Specify) 4641 464 I RISER SECONDARY CONTAINMENT ❑ I.STEEL N 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464k 4601 FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ® 4.CONTAINMENT SUMP 4518-c VIh UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE N 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 CERTIFICATE : I certify that this UST system is compatible with the hazardous substance stored and that the information provided(terelft is true,accurate, and in full compliance with legal requirements. APPLICANT NATURE DTE 470. i TrAM TE(print) 471. APPLICANT TI r 472. Co Ld tq I � - UPCF UST-B-1/41 Rev.(12/2007)