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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, 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 ❑ S. UST REMOVAL
<br />DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 430b
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<br />FACILITY ID P (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
<br />CITY 104
<br />2375 W. Grant Line Road
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<br />TANK ID 0 / 432
<br />TANK MANUFACTURER 433 TANK CONFIGURATION. THIS TANK IS 434
<br />Xerxes N LA STAND-ALONE TANK
<br />*;DieselID��'
<br />'-1
<br />❑ 2. ONE M A COMPARTMENTED UNIT.
<br />Complete one page for each compartment in the unit.
<br />DATE UST SYSTEM INSTALLED 435
<br />TANK CAPACITY IN GALLONS 476 NUMBER OF COMPARTMENTS M THE UNIT 437
<br />1991
<br />12000
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<br />TANK USE N la. MOTOR VEHICLE FUELING ❑ 1b. MARINA FUELING ❑ Ic. AVIATION FUELING 439
<br />❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 5. EMERGENCY GENERATOR FUEL [HSC §25291.5(e)]
<br />❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439a
<br />CONTENTS PETROLEUM: ❑ la. REGULAR UNLEADED ❑ to. MIDGRADE UNLEADED ❑ Ib. PREMIUM UNLEADED 440
<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 />❑ 11.0711ER NON -PETROLEUM (Specify): 4406
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<br />TYPE OF TANK ❑ 1. SINGLE WALL N 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 N 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445
<br />❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): ' 445a
<br />OVERFILL PREVENTION N 1. AUDIBLE & VISUAL ALARMS a 2. BALL FLOAT 13 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 N 2. DOUBLE -WALLED ❑ 99. OTHER 460
<br />SYSTEM TYPE N 1. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION t23 CCR §2636(a)(3)] 458
<br />PRIMARY CONTAINMENT ❑ 1. STEEL N 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464
<br />❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER(Specify): 464a
<br />SECONDARY CONTAINMENT ❑ 1. STEEL N 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464b
<br />❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464c
<br />PIPINGrMBINE CONTAINMENT SUMP TYPE ® 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE 464d
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<br />VENT PRIMARY CONTAINMENT ❑ 1. STEEL N 4. FIBERGLASS U 10. RIGID PLASTIC ❑ 90. NONE ❑ 99, OTHER (Specify) 464e
<br />464e1
<br />VENT SECONDARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464f
<br />464x1
<br />VR PRIMARY CONTAINMENT 1. STEEL ®4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE 99.OTHER (Specify) 4648
<br />464 1
<br />VR SECONDARY CONTAINMENT ❑ L STEEL N 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify)
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<br />VENT PIPING TRANSITION SUMP TYPE N 1. SINGLE WALL ❑ 2. DOUBLE WALL❑ 90. NONE 464i.
<br />RISER PRIMARY CONTAINMENT 19 L STEEL [14. FIBERGLASS Ll 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464j
<br />464' I
<br />RISER SECONDARY CONTAINMENT ❑ 1. STEEL N 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464k
<br />464k1
<br />FILL COMPONENTS INSTALLED ®l. SPILL DUCKET N 3. STRIKER PLATEMOTTOM PROTECTOR N 4. CONTAINMENT SUMP 45la-e
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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 (Specify) 469b.c
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<br />STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT N 6. ISOLATION449'
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<br />CERTIFIC T ' : I certify that this UST ys cm is compatible with the hazardous substance stored and that the information provided herein accurate,
<br />and in full com lian w' cal requirements.
<br />AP IC Ar s T RE
<br />TE 470.
<br />11111/2009
<br />AP ICA T NAME (p?fit 471'
<br />APPLICANT TITLE 472'
<br />Aura Si, le for She Prod cts US
<br />Shell Oil HS&E Coordinator
<br />UPCF UST -111 - 3/4 Rj,. ( 007)
<br />
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