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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 1,11,111,1V,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: 430a DATE EXISTING UST DISCOVERED: 4306
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<br /> FACILITY 1D N(Agency Use Only) tk � f INK?
<br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3
<br /> Grant Line Shell 136187
<br /> BUSINESS SITE ADDRESS 107 CITY 104
<br /> 2375 W.Grant Line Road Trac
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<br /> TANK ID N 472 TANK MANUFACTURER 433 TANK CoNFIGURATtow THIS TANK IS 434
<br /> 2-Plus Xerxes Z LA STAND-ALONE TANK
<br /> ❑2.ONE M A COMPARTMENTED UNIT.
<br /> Coniplele one page for each compartment in the unit.
<br /> DATE UST SYSTEM INSTALLED 415 TANK CAPACITY IN GALLONS 476 NUMBER OF COMPARTMENTS IN THE UNIT 433
<br /> 1991 j{y 12000�( p
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<br /> TANK USE ® la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439
<br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil ❑ 5.EMERGENCY GENERATOR FUEL IHSC§2528I.5(e))
<br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a
<br /> CONTENTS PETROLEUM: ❑ l a.REGULAR UNLEADED ® to.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440
<br /> ❑ 3.DIESEL ❑ 5.SET 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-PETROLEUMS if : 440i
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<br /> TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443
<br /> PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444
<br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a
<br /> SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445
<br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER S ecify)* 445a
<br /> OVERFILL PREVENTION ® 1.AUDIBLE&VISUAL ALARMS 012.BALLFLOAT LI 3.FILL TUBE SHUT-OFF VALVE 452.
<br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT
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<br /> PIPING CONSTRUCTION ❑1.SINGLE-WALLED ®2.DOUBLE-WALLED ❑99.OTHER 460
<br /> SYSTEM TYPE ® I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(aX3)) 458
<br /> PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464
<br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a
<br /> SECONDARY CONTAINMENT ❑ t.STEEL N 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b
<br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464¢
<br /> P[PINGlrURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644
<br /> c "mns.!'1 VENT;•YAP_®R:REQ®'V R .( 2)`.AND:RTS�EElt,� 'I IP.E�PIFI G CQNSTRUCTI®I�Jt •:.;".`-°,
<br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS U 10.RIGID PLASTIC U 90.NONE U 99.OTHER(Specify) 464e
<br /> 464e1
<br /> VENT SECONDARY CONTAINMENT 0 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464r
<br /> 464n
<br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 446 S
<br /> VR SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464h
<br /> 464hl
<br /> VENT PIPING TRANSITION SUMP TYPE ® 1.SINGLE WALL 0 2.DOUBLE WALL ❑ 90.NONE 4641.
<br /> RISER PRIMARY CONTAINMENT IN L STEEL 4.FIBERGLASS U 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464)
<br /> 464.1
<br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464k
<br /> 464k1
<br /> FILL COMPONENTS INSTALLED ® I.SPILL BUCKET C9 3.STRIKER PLATEMOTfOM PROTECTOR 0 4.CONTAINMENT SUMP 451"
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<br /> CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a
<br /> CONSTRUCTION MATERIAL ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER S cify 46%-c
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<br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ® 6.ISOLATION-r 448.
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<br /> CERTIFIC ON: I certify that thisUST stem is compatible with the hazardous substance stored and that the information provided herein is true,accurate,
<br /> and in full com 1 ance ith le al requirements.
<br /> PLI SI N RE DATE 470"
<br /> 11/11/2009
<br /> LI NAME(p I 471' APPLICANT TITLE 472.
<br /> Aura Sible for Sh it Prod cts US Shell Oil HS&E Coordinator
<br /> UPCF UST-B-1/4 Rev.(12/2007)
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