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IFIED PROGRAM CONSOLIDATED F
<br />UNDERGROUND STORAGE TANK
<br />OPERATING PERMIT APPLICATION - TANK INFORMATION (One form per UST)
<br />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
<br />X 1. NEW PERMIT ❑ 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION
<br />❑ 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL
<br />DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 430b
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<br />FACILITY ID # (Agency Use Only)III�p�11
<br />BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) 3
<br />Quik Stop #125
<br />BUSINESS SITE ADDRESS 103 CITY 104
<br />1580 W. Main Street Ripon
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<br />TANK ID # 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434
<br />1 Xerxes X 1. A STAND-ALONE TANK
<br />❑ 2. ONE IN A COMPARTMENTED UNIT.
<br />Complete one page for each compartment in the unit.
<br />DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437
<br />10,000 1
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<br />TANK USE x la. MOTOR VEHICLE FUELING ❑ lb. MARINA FUELING ❑ lc. AVIATION FUELING 439
<br />❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 5. EMERGENCY GENERATOR FUEL [HSC §25281.5(c)]
<br />❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439a
<br />CONTENTS PETROLEUM: X la. REGULAR UNLEADED 0 lc. MIDGRADE UNLEADED ❑ 1b. PREMIUM UNLEADED 440
<br />❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS
<br />❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (Specify): 440a
<br />NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL
<br />❑ 11. OTHER NON -PETROLEUM S ecif 440b
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<br />TYPE OF TANK ❑ 1. SINGLE WALL x 2. DOUBLE WALL ❑ 95. UNKNOWN 443
<br />PRIMARY CONTAINMENT ❑ 1. STEEL X 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444
<br />❑ 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 444a
<br />SECONDARY CONTAINMENT ❑ 1. STEEL X 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445
<br />❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 445a
<br />OVERFILL PREVENTION ❑ 1. AUDIBLE & VISUAL ALARMS ❑ 2. BALL FLOAT x 3. FILL TUBE SHUT-OFF VALVE 452,
<br />❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT
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<br />°CONSTRUCTION
<br />PIPING ❑ 1. SINGLE -WALLED x 2. DOUBLE -WALLED ❑ 99. OTHER 460
<br />SYSTEM TYPE x 1. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR §2636(x)(3)] 458
<br />PRIMARY CONTAINMENT ❑ 1. STEEL X 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464
<br />❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER(Specify): 464a
<br />SECONDARY CONTAINMENT ❑ 1. STEEL x 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464b
<br />❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464c
<br />PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE 464d
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<br />VENT PRIMARY CONTAINMENT ❑ 1. STEEL x 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464e
<br />464el
<br />VENT SECONDARY CONTAINMENT ❑ 1. STEEL x 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464f
<br />464171
<br />VR PRIMARY CONTAINMENT ❑ 1. STEEL X 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 4648
<br />464 1
<br />VR SECONDARY CONTAINMENT ❑ 1. STEEL X 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464h
<br />464h1
<br />VENT PIPING TRANSITION SUMP TYPE ❑ 1. SINGLE WALL x 2. DOUBLE WALL ❑ 90. NONE 4641.
<br />RISER PRIMARY CONTAINMENT x 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 4641
<br />464' 1
<br />RISER SECONDARY CONTAINMENT ❑ 1. STEEL x 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464k
<br />464kl
<br />COMPONENTS INSTALLED x 1. SPILL BUCKET x 3. STRIKER PLATE/BOTTOM PROTECTOR x 4. CONTAINMENT SUMP 45la-c
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<br />CONSTRUCTION TYPE X 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 469a
<br />CONSTRUCTION MATERIAL ❑ 1. STEEL x 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER S ecify 469b -c
<br />STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODES) ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION 448.
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<br />CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate,
<br />and in full compliance with legal requirements.
<br />APPLICANT SIGNATURE
<br />DATE 470.
<br />I�
<br />APPLICANT NAME (print) Dulcinea Covan 471.
<br />APPLICANT TITLE Compliance Manager 472.
<br />UPCF UST -B - 1/1 Rev. (12/2007)
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