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UNIFIED PROGRAM CONSOLIDATED FORM ® I. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (one form per UST) 4641 1 TYPE OF ACTION (Check one item only. For an UST permanent closure or removal, complete only this section and Sections 1, 11, 1II, IV, and IX below) 430 ❑ 1. NEW PERMIT ❑ 3, RF.NF.WAL PERMIT ® 5, CHANGE OF INFORMATION FILL COMPONENTS INSTALLED ❑ 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL 451 a -c DATE UST PERMANENTLY CLOSED: 4308 1 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION CONSTRUCTION TYPE FACILITY ID # (Agency Use Only) { CONSTRUCTION MATERIAL ❑ 1. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 469b -c BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) 3 Grant Line Shell BUSINESS SITE ADDRESS 107 CITY 104 2375 W Grant Line Road 1 Tracy II, TANK DESCRIPTION TANK ID # 472 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 -r,A Xerxes ®1. A STAND-ALONE TANK 01"169 02, ❑ 2. ONE M A COMPARTMENTED UNIT, Com leis 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 1991 12000 III. TANK USE AND CONTENTS TANK USE ® 1 a, MOTOR VEHICLE FUELING ❑ 1 b. 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: ® I a. REGULAR UNLEADED ❑ Io. MIDGRADE UNLEADED ❑ 1 b. PREMIUM UNLEADED 440 ❑ 3. DIESEL ❑ S. 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): 440b _ IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ® 2. DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT ❑ I. STEEL N 3. FIBERGLASS ❑ 6, INTERNAL BLADDER 444 ❑ 7. STEEL+ INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ I. STEEL N 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445 ❑ 90. NONE ❑ 95. UNKNOWN [199. OTHER (Sci 445a OVERFILL PREVENTION 1. AUDIBLE & VISUAL ALARMS Lj 2. BALL FLOAT 3. FILL TUBE SHUT-OFF VALVE 452, ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/ WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1. SINGLE -WALLED ® 2. DOUBLE -WALLED [199, OTHER 460 SYSTEM TYPE ®1 PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4, SAFE SUCTION [23 CCR §2636(8)(3)] 458 PRIMARY CONTAINMENT ❑ 1. STEEL N 4. FIBERGLASS ❑ 8. FLEXIBLE. ❑ 10. RIGID PLASTIC 464 ❑ 90 NONE ❑ 95. UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL ® 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGIDPLASTIC 464b ❑ 90 NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464c PIPING/I'MINE CONTAINMENT SUMP TYPE ® 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE 4644 W. VENT, VAPOR RECOVERY- (VR) AND ,RISER/ FILL PIPE PIPING.CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90, NONE ❑ 99. OTHER (Specify) 464e 464e1 VENT SECONDARY CONTAINMENT 1. STEEL N 4. FIBERGLASS 10. RIGID PLASTIC D 90. NONE 99. 0 -1 -HER (Specify) 4691 464n VR PRIMARY CONTAINMENT 13 1. STEEL 0 4. FIBERGLASS ❑ 10, RIGID PLASTIC 0 90. NONE C1 99. OTHER (Specify) 4648 464 I VR SECONDARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS 10. RIOID PLASTIC 0 90. NONE 99. OTHER (Specify) 464h AAAk1 RISER PRIMARY CONTAINMENT ® I. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 48+1 4641 1 RISER SECONDARY CONTAINMENT ).STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90, NONE C3 99. OTHER (Specify) 464k 4601 FILL COMPONENTS INSTALLED 1. SPILL BUCKET ® 3. STRIKER PLATUBOTTOM PROTEC'T'OR N 4, CONTAINMENT SUMP 451 a -c VQ. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® 1. SINGLE WALL ❑ 2, DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 469a CONSTRUCTION MATERIAL ❑ 1. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 469b -c VIII, CORROSION PROTECTION STEEL COMPONENT PROTECTION [12, SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT ® 6, ISOLATION 448. IX. APPLICANT SIGNATURE n CERTIFICATIO ; I certify that this UV system is mpatible with the hazardous substance stored and that the information provided herein Is 44il j R4yurate, and in full eompliairce4itoi ents. APPLICANTS DATE � 470. e: 1/27t2011 APPLICANT NAWTg (Print) , _ _ • n „. 471. AP,pj IaCA2�T�IT�L E s ^ /n 472. UPCF UST -8 -1/4