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r� a -tf4)64V UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (One form per UST) 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 ❑ L NEW PERMIT ❑ 3. RENEWAL PERMIT N 5. CHANGE OF INFORMATION ❑ 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 430e 1 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID N (Agency Use Only) "r _ V _ I BUSINESS NAME (Same as FACILI'T'Y NAME or DBA -Doing Business As) 3 Grant Line Shell BUSINESS SITE ADDRESS 101 2375 W. Grant Line Road CITY 104 Trac II. TANK DESCRIPTION TANK TD # 472 O�� TANK MANUFACTURER 473 Xerxes TANK CONFIGURATION: THIS TANK IS 434 ® 1,ASTAND-ALONETANK ❑ 2. ONE M A COMPARTMENTED UNIT . Complete one page for each compartment In the unit. DATE UST SYSTEM INSTALLED 415 1991 TANK CAPACITY M GALLONS 436 12000 NUMBER OF COMPARTMENTS IN THE UNIT 437 M. TANK USE AND, CONTENTS TANK USE ® 1 a. MOTOR VEHICLE FUELING ❑ I b. MARINA FUELING ❑ 1 c. AVIATION FUELING A39 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 5, EMERGENCY GENERATOR FUEL (HSC §25281.5(o)) ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439e CONTENTS PETROLEUM: ❑ I e. REGULAR UNLEADED ❑ l c. MIDGRADE UNLEADED ® 1 b. PREMIUM UNLEADED 440 ❑ 3, DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (Specify): 440a NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ❑ 11. OTHER NON -PETROLEUMS eci 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ® 2. DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAJNMENIT ❑ 1. STEEL N 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 ❑ 7. STEEL+ INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER S c[ ; 444e SECONDARY CONTAINMENT ❑ I. STEEL N 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LTNER ❑ 7. JACK13TED 445 ❑ 90. NONE [195, UNKNOWN [199. OTHER(Specify): 445a OVERFILL PREVENTION ® I. AUDIBLE 8c VISUAL ALARMS C3 2. BALL FLOAT ISI 3. FILL TUBE SHUT-OFF VALVE 452• ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION E UTMENT V. � PRODUCT'/ WASTE:PIPING :CONSTRUCTION . PIPING CONSTRUCTION ❑ 1. SINGLE -WALLED ® 2. DOUBLE -WALLED ❑ 99. OTHER 460 SYSTEM TYPE ® I. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR §2636(a)(3) 458 PRIMARY CONTAINMENT ❑ I. STEEL N 4, FIBERGLASS ❑ & FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL N 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464b ❑ 90. NONE ❑ 95, UNKNOWN ❑ 99. OTHER (Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ® 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE 464d VI. VENT; VAPOR RECOVERY (VR) AND RISER /FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ L STEEL 4. FIBERGLASS 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OnMR (Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ L STEEL 0 4. FIBERGLASS El 10. RIGID PLASTIC 90, NONE 99. OTHER (Specify) 464E 4601 VR PiCR Y CONTAINMENT ❑ L STEEL 0 4. FIBERGLASS C3 10. RIGID PLASTIC 0 90, NONE 99. OTHER (Specify) 4648 4641ti VR SECONDARY CONTAINMENT ❑ L STEEL 0 4. FIBERGLASS 10. RIGID PLASTIC C3 90. NONE ❑ 99. OTHER (Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE ® 1. SINGLE WALL El 2. DOUBLE WALL 0 90. NONE 4641. RISER PRIMARY CONTAINMENT N 1. STEEL 4. FIBERGLASS ❑ 10. RIGID PLASTIC U 90. NONE ❑ 99. OTHER (Specify) 4641 464JI RISER SECONDARY CONTAINMENT I, STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99, OTHER (Specify) 464k 464k1 FILL COMPONENTS INSTALLED ® I. SPILL BUCKET ® 3. STRIKER PLATEIBOTTOM PROTECTOR 0 4. CONTAINMENT SUMP 45la-c VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 469a CONSTRUCTION MATERIAL ❑ ],STEEL ® 4. FIBERGLASS IQ RIGID PLASTIC ❑ 99. OTHER(Specify) 469b.o VIII. • CORROSION PROTECTION STEEL COMPONENT PROTECTION [12. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT ® 6. ISOLATION 448' IX. APPLICANT SIGNATURE CERTIFICATIO : I certify that this UST system Is compatible with the hazardous substance stored and that the Information provided kg Mn. it true, accurate, and in full com lien with legal requirements. APPLICANTS ATURE Xf /,I Len DATE 470 1/27/2011: APPL T( rint) 471' nrh Ike -191 PLICAN TIT E '�14; 472' VLII a eek 4, 4` UPCF UST -B - 2/4 rev. (12/2007)