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4 i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <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 /> ❑ 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: 4wa DATE EXISTING UST DISCOVERED: 430b <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) 1 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 <br /> QUIK STOP MARKET#125 <br /> BUSINESS SITE ADDRESS 103 1 CITY 104 <br /> 1580 WEST MAIN STREET RIPON <br /> H.TANK DESCRIPTION <br /> TANK ID 432 TANK MANUFACTURER 433 TAIJK CONFIGURATION: THIS TANK IS 434 <br /> TANK#3(I�ESEL) XERXES M7I.ASTAND-ALONE TANK <br /> [12.ONE IN A COMPARTMENTED UNIT. <br /> Carnplete one page for each connpaduLm in the mrit <br /> DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 <br /> MARCH 28, 1985 8,000 1 <br /> III.TANK USE AND CONTENTS <br /> TANK USE la.MOTOR VEHICLE FUELING ❑ ib.MARINA FUELING ❑ lc.AVIATION FUELING 439 <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL(HSC 1252a1.5(c)l <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a <br /> CONTENTS PETROLEUM: a.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 <br /> V.DIESEL ❑ S.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(Specify): 440b <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ I.SINGLE WALL .DOUBLE WALL ❑ 95.UNKNOWN 445 <br /> PRIMARY CONTAINMENT ❑ I.STEEL DF3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 <br /> ❑ 7.STEEL+INTERNAL ENING [395.UNKNOWN [199.OTHER (Specify): 444a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER( i 445& <br /> OVERFILL PREVENTION ❑ 1.AUDIBLE dt VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODU /WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑ .SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER 460 <br /> SYSTEM TYPE 1.PRESSURE ❑ .GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR 12636(a)(3)1 458 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL U4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 <br /> ❑ 90.NONE 1125.UNKNOWN ❑ 99.OTHER(Specify): 464a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL Jr4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464b <br /> ❑ 90.NONE ❑ .UNKNOWN ❑ 99.OTHER(Specify): 464c <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL 9o.NONE 464d <br /> VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e <br /> 464e1 <br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC N 90.NONE ❑ 99.OTHER(Specify) 464f <br /> 464ff <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4646 <br /> 464al <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC W 9o.NONE ❑ 99-OTHER(Specify) 464h <br /> 464h1 <br /> VENT PIPING TRANSITION SUMP TYPE ❑ .SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 4641. <br /> RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4643 <br /> 464'1 <br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464k <br /> 464kl <br /> FILL COMPONENTS INSTALLED Irf SPILL BUCKET 3.STRIKER PLATEIBOTTOM PROTECTOR gr4.CONTAINMENT SUMP 45laa <br /> VII.UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE X1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a <br /> CONSTRUCTION MATERIAL Ur 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bc <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448. <br /> IX. APPLICANT SIGNATURE <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 com liiaannce ith l requirements. <br /> APPLICANT SIGNATURE e� / DATE April 8, 2010 470. <br /> APPLICANTNAME MikeKarvelot, for 471. APPLICANTTITLE Director of Environmental 472, <br /> Quik Stop Markets, Inc. Affairs <br /> TIPCFTIRT-R-1/2 r ;,� Ray.f12/2M171 <br />