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IFIED PROGRAM CONSOLIDATED F 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 X 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: 431a DATE EXISTING UST DISCOVERED: 430b F I I,Ih I r liltltl rll4'I l lfi Pl lh WIN � " "' ', �II IIN � u 1,11NII IIII '. Np),�;"".." FACILITY ID # (Agency Use Only) BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) 3 Quik Stop #125 BUSINESS SITE ADDRESS 103 CITY 104 1580 W. Main Street Ripon , m ' L. p�Ipp' l ll�i� ' ''; ' ' `a? a.�..": r'z ' ra 'n��• ,p ,r • . a ' u a PI' I� I iI IIII k7ylFPl II IIIIII ".,:, . ,ra' II. I, s>^ TANK ID # 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 2 Xerxes X 1. A STAND-ALONE 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 10,000 1 VV I N9 Il f7"� „ IX � d�l'±� �Ex9' r,lsa, ,, "ryl IFII 'il III Illgltllp VI ' '� k «1 I, ^ NEN 11 lIhIVtlG .,.,... l rvltti:i.I.II �lilf " tirvi: .:. •, .e. Y.. a. `row"�'.a»�Il,l ..., ". rvlu. �,.�.N., «, TANK USE x la. MOTOR VEHICLE FUELING ❑ lb. MARINA FUELING ❑ lc. AVIATION FUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 5. EMERGENCY GENERATOR FUEL [HSC §25281.5(c)] ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la. REGULAR UNLEADED ❑ lc. MIDGRADE UNLEADED X lb. 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)' �4P4ld1j43i 1.� .i011V +1ab IS 01 TYPE OF TANK ❑ 1. SINGLE WALL x 2. DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1. STEEL X 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 ❑ 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1. STEEL X 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 x 3. FILL TUBE SHUT-OFF VALVE 452. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT 1„ I I� W 'bk' I„'�ry VIII d v W p l",Ii�Q I� pa M . R y „ v,'� PIPING CONSTRUCTION ❑ 1. SINGLE -WALLED x 2. DOUBLE -WALLED ❑ 99. OTHER 460 SYSTEM TYPE x 1. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR §2636(a)(3)1 458 PRIMARY CONTAINMENT ❑ 1. STEEL X 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1. STEEL x 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 464d Geyrva+14"111 "rv� VENT PRIMARY CONTAINMENT 0 1. STEEL x 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ 1. STEEL x 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464f 464n VR PRIMARY CONTAINMENT ❑ 1. STEEL X 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 4648 464RI VR SECONDARY CONTAINMENT ❑ 1. STEEL X 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 1. SINGLE WALL x 2. DOUBLE WALL ❑ 90. NONE 464i. RISER PRIMARY CONTAINMENT x 1. STEEL El 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 4641 464' I RISER SECONDARY CONTAINMENT ❑ 1. STEEL x 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464k 464k1 FILL COMPONENTS INSTALLED x 1. SPILL BUCKET x 3. STRIKER PLATE/BOTTOM PROTECTOR x 4. CONTAINMENT SUMP 4514-c CONSTRUCTION TYPE X 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 469a CONSTRUCTION MATERIAL ❑ 1. STEEL x 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHERS eci 469b -c lk uIMIy ' IIIIII! Illi fir' IIII o� ,' IIw 114 " . n 11. . Rg xr 11i l " .eh 111 11 'I,l lil �� I�I�III III 11 VI qhl 1'I IV, °{„ Il !I,?';,(4 aipl lurk;, ,T's. �! ,1�1n'Pkr� N �` II ul� II 1111 I II II' NIIV XVIII .,� 111911 I I �� IIII! x. Illlti,lu ,w III ( .,.�. STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION 448. 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 470. APPLICANT NAME (print) Dulcinea Covan 471. APPLICANT TITLE Compliance Manager 472. UPCF UST -11 - 1/1 Rev. (12/2007)