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PROGRAM CO ATED FORNrr 1711011,9 UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION One form pa USI) TYPE OF ACTION (Check one itom only. Foran UST Permanent closure or ramovaL OMPlete only this sectiam and Sections 1,11,III,TV,and VC below) 430 ❑ i.NEW PERMTT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7_UST PERMANENT CLOSURE ON SITE M&UST REMOVAL DATE UST PERMANENTLY CLOSED: 4 DATE EXISTING UST DISCOVERED: 430b FACILITY ED#(tlgeacy Use y-) v t BUSINESS NAME(Sam as FACILITY NAME or DBA-Doing Busimess As) am 3 Walmart- BUS]NESSSITE ADDRESS 103 MY Trac CA 104 10 W Grant Line Rd Y� TAM ED# 432 TANXMANUFACTURER TAwcoNrlamnow.TH44TANKIs 434 _ Containment Solutions R LASTAND-ALONBTANK 2-OM IN A COMPARTMENTED UNIT. Dean each inarmit DATE UST S STEM INSTALLED %is K CAPACITY IN GALLONS NUMBER O COMPARTPABM IN THE UNIT 437 5v 1a 'AM ' TANK USE ❑ k MOTOR VEHICLE FUELING ❑ !b.MARINA FUBLI NQ ❑lc.AVIATION FUELING' 4 9 Q 3.CHEMICAL PRODUCTSTORAGE ❑4.HAZARDOUSWASTEMdW=Used09) ❑5.11MERGEERATORPUEi,(BSC42sJti31OI. ❑6.OTHER GENERATOR FUEL 1395.UNKNOWN . 1399.071m= New Motor 011% CONTENTS PETROLEUM: ❑ la.REGULAR.UNLEADED 13 Ic,MIDGRADE UNLEADED ❑ ib.PREMIUM UNLEADED ❑3.DIESEL ❑5.JET FUEL ❑6.AVIATION GAS D 8.PETROLEUM BLEND FUEL ©9.OTHER PETROLEUM NON-PETROLEUM:13 7.USED OIL ❑ 10.ETHANOL 1-4 11.OTHER NON-PETROLEUM New Motor Oil 40 TYPE OFTANK 1.SINGLE WALL 2 DOUBLE WALL Q9S.UNKNO PRIMARY CONTAINMENT ULSTBEL 0 3.FIBERGLASS ❑6.INTERNAL BLADDER ❑7.STEEL+INTERNAL LINING 95.UNS 21-1- ❑99.OTMM 444a SECONDARY CONTAMWff I.STEEL 3.FIBERGLASS 6.EXTERIOR MEMBRANE LINER ❑7-JACKETED 445 0 90.NONE El 95.UNKNOWN 99.OTHER 0222!§2:0 44% OVERFILL PREVENTION I.AUDIBLE&VISUAL ALARMS 2.BALLFLOAT 3.FILL TUBE SHUT-OPF VALVE 451 ®4.TANK MEETS REQUIREMENTSFOR EMbeTK)NFROM OVERFILL PREVENTION 4QUIPNfflNT --two + " ON. PIPING CONSTRUCTION 1.SINGLE-WALLED 2.�UBLE-WALLED OTHER � SYSTTIMTYP$ ❑1.PRESSIIRE 2 V1TY CONYENT(ONALSUCTION C34.SAFESUM0NMOqP§WX4N 458 PALMARY CONTAINMENT JU I.STEEL ❑4.FIBERGLASS U 8.FLEXIBLE 10.RIGID PLASTIC ❑90.NONE ❑95.UNKNOWN ❑99.OT ) 464a SECONDARY CONTAINMENT M 1.STEEL Lj 4.FIBERGLASS Ll 8.FLERIBLE t0.RIGIDPLASTIC 464b ❑90.NONE ❑95.UNKNOWN ❑99.OTHBR( 464e PIPINGMURBINE CONTAINMENT SUMP TYPE W 1.SINGLE WALL 73 2.DOUBLE WALL 0 90.NONE V1TNf PRI►4ARY CONTAINMENT U I.STEEL _U 4.FIBERGLASS U 10.RIGIDP R; Li 90.NONE U 94 OTHER(Sps*) 464 VENT 9 R00-DWAMY CONTAINMENT 13 1.sTE& E3 4.FIBERGLASS Q 10.RIGIDPLASTIC 13 90.NONE C3 99.OTHBR(Spw*) 4B4A VRPRINARY CONTAtMMEN1 El I.STEEL 0 4.FIBERGLASS E3 IO.RiGIDPLASTIC E3 90.NONE E3 99.OTm apaw 464s VR SECONDARY CO AINMENT 0 1.STEEL C3 A.FIBERGLASS E3 I0.RIGIDPLASTIC C1 90.NONE 13 99.OTHER(Sped jy)VwU469b 464h1 PIPING TRANSITION SUMP TYPE 0 1.SINGLE WALL 13 2.DOUBLE WALL 13 90.NONE RURPRiMARY CONTAINMENT 1.STEEL E3 4. GLASS Q IO.RIM PLASTIC U 90.NONE E3 99.OT1E:R(Spv*) 4641 RISER SECONDARY CONTAINMENT 1.STEEL 4.FIBERQLA3S IO.RIGIDPLASTIC 90.NONE 99.OTH (Sp ERpaij) k 4Mk1 FILL COMPONENTS INSTALLED I.SPILL BUCKET3.STRICBR PLATEMOTTOMPOaTECTOR 4.CONTABNM� c SUMP 451a 77 469A C181RiJCfIDN TYPE I.SINGLE WALL 2.DOUBLE WALL E33.NO DISPENSERS 90.NONE UCT1001 MATERIAL 1.STEEL. 4.FIBERGLASS Q 10.RIGID PLASTIC 99.OTHER( ) 459b•c ., . . STBBL COMPONENT PROTECTION ❑1 SACRIFICIAL ANODE(S) . ❑4.IMPRESSED CURRENT ❑6.iSOLATriNN a4a CERTIFICATION:I certify that this UST system Is compatible with the hazardoms=bstanee dared and that the htform Mon provhled herein is true,awumte, and in fA conyllem with kxsl requInments. SRiNA�TRE r � ala DATE& // d/f' APPLICANT NAME(prick) 47t. APPUC 47Z. Covington Maass fermi Coordinator, BRR Architectur UPCF UST-11-in Rev.(1=001)