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NIFIED PROGRAM CONSOLIDATED UNDERGROUND STORAGE TAN 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 tion and Sections I,II,III,IV,and IX below) 430 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 0;03 1 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 Valero Corner Store #3698 BUSINESS SITE ADDRESS 103 1 CITY 104 153 E. I I m Street Trac II.TANK DESCRIPTION TANK ID# 3698-3 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 I /t Modem Welding O 1.A STAND-ALONE TANK C�Vh D{� G 2.ONE IN A COMPARTMENTED UNIT. Complete one pue for each com anme,in @e unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 10/01/1987 10,000 III.TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE urcicdw Used O8) ❑ 5.EMERGENCY GENERATOR FUEL[HSC¢25281.5(c)l ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ® lb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440e NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 441m IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 43 PRIMARY CONTAINMENT ® 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (specify): 444a SECONDARY CONTAINMENT ❑ I.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ®99.OTHER(Specify): FRP coated steel 445a OVERFILL PREVENTION ® I.AUDIBLE&VISUAL ALARMS ❑ 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 ❑I.SINGLE-WALLED ®2.DOUBL&WALLED ❑99.OTHER ae0 SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR 42636(,)(3)1 458 PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ &FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(S cify): 4646 SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ &FLEXIBLE ❑ 10.RIGID PLASTIC 4641, ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ® I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464c 464e1 VENT SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify) a64f 464(1 VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 4641. RISER PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) (A 11 464'1 RISER SECONDARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464kl FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ® 4.CONTAINMENT SUMP 451a-c VIL UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469, CONSTRUCTION MATERIAL ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469h, VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ® 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full compliance with legal requirements. APPLICANT SIGNATURE &,a DATE 3 (7 9') (5 47 0. APPLICANT NAME(print) Sandy Huff Q 47' APPLICANTTITLE Compliance Coordinator 472' UPCF UST-B-112 Rev.(12/2007)