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UNIFIED PROGRAM CONSOLIDATED FORM
<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 1,II,111,IV,and IX below) 430
<br /> ❑ I.NEW PERMIT ❑ 3.RENEWAL PERMIT N 5.CHANGE OF INFORMATION
<br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL
<br /> DATE UST PERMANENTLY CLOSED: 7 43oa DATE EXISTING UST DISCOVERED: 430b
<br /> � _`•a.1 '..�' _�.'. fi, :"'{ nBifyliACII�ITY'I�IF®R1Vi��,T�Q1V`'' S.}{�{{{�d�'TN4.:e.��y Ve•t $?�,,'�4Y4� `�h#.. YL'h�4.dJ.e-�
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<br /> FACILITY ID#(Agency Use Only)
<br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3
<br /> Grant Line Shell 136187
<br /> BUSINESS SITE ADDRESS 103 CITY 104
<br /> 2375 W.Grant Line Road Trac
<br /> TANK•DESCRIPTION
<br /> TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION.THIS TANK 1S 974
<br /> 1-Regular Xerxes ®I.A STAND-ALONE TANK
<br /> ❑
<br /> 2.ONE IN A COMPARTMENTED UNIT.
<br /> complete one page for each compartment in the unit.
<br /> DATE UST SYSTEM INSTALLED 415 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437
<br /> 1991 12000
<br /> ti!`t`• t5'i rx, v` , f'{° lt• �• t ('�'NUEAT \CP -r X((b.4ll . x . fAY`f.r'.
<br /> TANK USE N la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ to.AVIATION FUELING 439`
<br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) El S.EMERGENCY GENERATOR FUEL(HSC 125281.5(c)]
<br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439&
<br /> CONTENTS PETROLEUM: N la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED a4o
<br /> ❑ 3.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 /> ❑
<br /> 11.OTHER NON-PETROLEUM(Specify): 4401;
<br /> " -Y r 3 � '�.�. -u r � Ira Yy,ty,{a}rf�2 ifs` �/ s' T�Z�•l A7 an TT(����` I�fi Y{9k,rcr'��4 xPy,E f8�:.f'.R t_: ""'"�1 hf "3'JS 93. �Ly rwi<e
<br /> I?.. '.*�-�}sA..+��It;1ed�;'t�. t.• irL`Y" �,"s:AN'CE¢ .''t!s� i?�t �Yf �A,�lA is®lir�l• 4C:`.':Ya�o'l-'krP4`�ifi. �°w��Ft�,.s. e��'fY;.l�.z•:.-!K !,Y,r...ira•`f 1. .� F p••i ti�T�1
<br /> TYPE OF TANK ❑ 1.SINGLE WALL N 2.DOUBLE WALL ❑ 95.UNKNOWN 443
<br /> PRIMARY CONTAINMENT ❑ 1.STEEL N 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444
<br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a
<br /> SECONDARY CONTAINMENT ❑ 1.STEEL N 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445
<br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER S ify): 445a
<br /> OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS ® 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452.
<br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT
<br /> Y ' ah >.�r h•.- °,. �f�F-rr - a. i - x., ear t rs*{.
<br /> ,'ie J 'S� I"^= +3} '..iIIA�.. T:liQLP ,YJ 1;/ AII� �S.I to\,,V�p6:� �T;RU4:8!-®N -f ,�i^ i-t?nt-r-, .s•rn>_:•.:v lM..:slte'are,:%I%
<br /> PIPING CONSTRUCTION ❑1.SINGLE-WALLED N 2.DOUBLE-WALLED ❑99.OTHER 460
<br /> SYSTEM TYPE N ].PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR§2636(ax3)] 458
<br /> PRIMARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ &FLEXIBLE ❑ 10.RIGID PLASTIC 464
<br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHERS i ): 464a
<br /> SECONDARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b
<br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4fi4c
<br /> PIPINGfTURBINE CONTAINMENT
<br /> �7SUMP
<br /> }TYPE /(/�■® 1.SINGLE`WA®LI�LTf��❑ 22+.DOUBLE W�A�LL$�$1 ❑1 9/0..NONEEi�n�]T►/�r7�[ *T 464d
<br /> .fr...-:h.-t.Y.ki �,l�r$p�iii>,7rAy�1.,,T�9 AL'M1®��\!,T;.4%�'1AY J�,L+..Y!�,•1VilEl®�,�.II�Lif•'1.1'L' A;Lr 11767 6i®��71 Li l'J 1.111®1\ gt.c{�s... 'h,-k=yE 3^-:
<br /> VENT PRIMARY CONTAINMENT ❑ L STEEL N 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE Lj 99.OTHER(Specify) 464c
<br /> 464e1
<br /> VENT SECONDARY CONTAINMENT 11 L STEEL 0 4.FIBERGLASS E3 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 464r
<br /> 464n
<br /> VR PRIMARY CONTAINMENT 0 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648
<br /> 464 1
<br /> VR SECONDARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464h
<br /> 464hl
<br /> VENT PIPING TRANSITION SUMP TYPEN I.SINGLE WALL 2.DOUBLE WALL El 90.NONE 4641.
<br /> RISER PRIMARY CONTAINMENT N 1.STEEL ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NOME Ll 99.OTHER(Specify) 4641
<br /> 4"1
<br /> RISER SECONDARY CONTAINMENT L STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464k
<br /> 464kl
<br /> FILL COMPONENTS INSTALLED N I.SPILL BUCKET N 3.STRIKER PLATE/BOTTOM PROTECTOR N 4.CONTAINMENT SUMP 451a-c
<br /> -k yrif 5�tl �f' Yt ) .K , ....,. •r V .111 HA. `6•ip St
<br /> F,4rc?ifi •aP{Ai<':fiSYxu' t{a's.i.->>�e''t; cI UiD„L'RbIPENSE•, µ. 71. r"
<br /> CONSTRUCTION TYPE N I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE- 469a
<br /> CONSTRUCTION MATERIAL ❑ L STEEL N 44.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(S city) 469b-e
<br /> -= :$ t a g �+r� xn y 7�:y`• •y't`• h° •,•y s
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<br /> :ti. s~ .YJ1,'4...P.1l � r'�
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<br /> .:'hcI .7 .�4'1'o<e't_^i u .� :4r�i f...yk'r'3f17r @ ,r:F:, ,•tt*t Ty _.ao rr9l .' r°:f :•t'_ .
<br /> STEEL COMPONENT PROTECTION [12.SACRIFICIAL ANODE(S) C14.IMPRESSED CURRENT N 6.ISOLATION 448•
<br /> 9 '7a Mw lj�C�sl� aY.1r�' �r1J' .j AT r �'�p� p,. s.1, '1 i F•
<br /> <•=til f:: J.7-1�•^.tt1.i{ 7u.J 13a_•r X6' :�•t'd.+h"=i f�i�4�44'i43a.rf .aA�$L�� �r`9��Tk.1��.K?ea'm'yi' [��' f-r.=��t� w s iJ y tl+r•,Pi *1t).;..
<br /> CERTIFICAT ON: I cert tIJ t this UST system is co pat' le with the hazardous substance stored and that the information provided herein is true,accurate,
<br /> and( f Ii com ian a with legal re4uiF6ments.
<br /> A LIC SIG ATUR DATE 470'
<br /> 11/11/2009
<br /> APP ICA f NAME(prii I) 471' APPLICANT TITLE 472.
<br /> Aura Sibla for She Oi[ProductsUSV Shell Oil HS&E Coordinator
<br /> UPCF UST-B-1/4 Rev.(12/2007)
<br />
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