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12/22/2011 15:08 20946401`36 trvV1I[urvmrwlr+� rl�w UNIFIED PROGRAM CONSOLIDATED FORM llQ �Z, x lel UNDERGROUND STORAGE TANK b� OPERATING PERMIT APPLICATION-TANK INFORMATION one Imn er Us TYPE OF ACTION (Cheek one ikln oldy. Foran UST pcvnanenl.dofure or removal,compine only 1N5 Suction and Sections L II,IR IV,and IX below) 10 ❑ 1.NEW PERMIT ® 3.REWFWAL PERN T ❑ 5.CHANGE OF INFORMATION �.Y Cl 6.TEMPORARY LIST CLOSURE Ej T.UST PERMANENT CLOSURE ON SITE M R USTREMVAL 1 DATE UST PERMANENTLY CLOSED 1°m DATE EXIcr7NC VST DISCOVERED. nna L TACIL[fy'TNFORMAT[ON FACILITY ID6(49vwyum Qbw 13 19' 1613L BUSINESS NAME(Sama=FACILITY NAMF,or DBA-D ITIS ufi ) �� I VED BUSINESS SITE ADDRESSW. BEC ty . . '. .. .. . :. .. II.TANKDESCRIPTION;• . . 201I TANK;70 d OH TANK MANU AC-R3RER "5) TANK CONFIGURATION' TOGS TANII 15 N5+ 1.A STANDALONE TANK SAN JOAQUIN192.OEAcARmiI N TY( 0 3268' rrI �CEE VSERV/C A LIST SYSTEM INSTALLED TANK CAPACITY IN GALLONS " NUMBER OF COMPARTMEN75 M THE UNIT EB U . . . IO,.TANK USE AND CON-YEN", TANK USE E MOTOR YEHICLR RLIRI.INC 0'Ib.MARINA FUELING ❑ Ie.AVLATION FUELINGOl. 0 3.CHEMICAL PRODUCT STORAGE 0 e.NAUROOUS WASTS#. a Iw IFo O 5.EMERGENCY GENERATOR NEL MSC w°zrl Nql a.OTHEA GENERATOR FUEL 095,VNKHOWN ❑ 99-OTHER(S ): It"" NTS PRIROI.ELIM: •REGULAR UNLEADED 0 le.MtOGRADEUNLEADED 0 Ib.PREMIUM UNLEADED •i0 ❑ 3.lwv5 0 $.JET FUEL 0 6.AVIATION GAS ❑ R PETROLEUM BLEND FUEL 0 9.OTHER PETRtF R,,.W S c N0"PTI OLSUM. T.1.5ED OIL 0 m.ETHAVOL (3 11 NON.PETROI,T,UM(Sl,*). 440% IV. TANK CONSTRUCTION TYPEOF TANK 0 1.SINGLE WALL 2M.DOUBLE WALL tj 9S.UNKNOWN PAIMMY GGNTAINMEM ❑ 1.STEEL W.4-4111111ROLA19 0 6.INTERNAL RI.AODFR "• 0 TSTEEL+INTERNAL LINING O 95.UNKNOWN 0 99.OTHER (Specify)'. SECONDARY CONTNNMENT 1.SIEP.L _ ERGLASS ❑ 6-EXTERIOR MEMHRANE LINER ❑ T.IACKFWJ) Nt Ll 90 NONE [3 95.UNKNOWN 99.OTHER R Nsn OVERFn,i PREVENTION LAUDIM.EIYRUALALARMS ).MALL FLOAT .. ILL TUBE SHVT-OFF VALVE •n, ❑ e.TANK MEETS REQUIREMENTS FOR F.XEMFTX NFROM OVERFILL PREVENTION EQuwHENT V, PRODUCT/.WASTEPIPINGCONSTRUCTION PIPM CON9TRUPIOLE•WAUED eTDOUBL&WALLED 099.0melt 000 SYSTE3 TYPE 1,PRESSUREiOMVTTY ❑ ]CONVENTIONAL SUCTIONa,SAFE SUCTION III LCR R9)prNDl aef PRIMARY CONTAMh1EeT 0 1,STEEL ©T FIBERGLASS ❑ {.FLEXIBLE 0 lo.RIGID PLASTIC •N ❑90.NONE ❑ 95.UNKNOWN 99.OTHERI SECONDARY CONTAINMENT El I,STEEL .FIBERGLASS 0 F.FLEXIBLE 0 10.RAID PLASTIC Aa+4 0 ".NONE "UNKNOWN 0 99.OTNER(sp"l y 1N. PIPBW/IURBBNE CONTAINMENT SUMP TYPE .RINGLF WALL Ll S.DOUBLE WALL U 90.NONE .a+n ' :ii '.VI:VENT;VAPOR RECOVERY M AND RISER/FILL PIPE PIPING CONSTRUCTION VENTPRIMARY CONTAINMENT .STEEL 0 4,F 10,RIGID PLASTIC El 90.NONE 099.OTHER(5P"ciy) •a"i VENT SECONDARY MKTAIN9AFNT U I.STEEL U N.FIBERGLASS 010.MOID PIAT: NONF, CIw,OTRFR +"(7 Vie PRIMARY CONTAINMENT 0MEl- FIBFRGI,ASS Ll 70.RIGID PLASTIC U 90.NONE L399.OTHER(SPhNry) "a4 VR SECONDARY COFTTApNMENT I.STEEL UN.FIBERGLA.NS 010.RI(:m PI,ASTiC E 099.OTHER(SWiy) +� +NEI VENT PIPING TRANSITION SUMP TVPE 1,SPOOLF.WALL t.DOUBLE WALL .NONE •N. RISER PRIMARY CONTAINMENT 0 1.STEEL e.FIBERGLASS 10,RIGID PLASTIC .NONE 0 99,DTHF,R(6PR1rY) "0.1 +N I RISER SECGNOAKY CONTAINMENT EF 1STEEL Oe.FIBERGLASS 010.XOGID PLASTIC 3,115,NONE LI 99.OTHER(Speny) "NN N41 BL COMPONENTS BNSTAILBD ,$Pn.LelKl(ET ..STRIICFR riATFiBOTTOM PROTECTOR C34CONTAINMENTsump A51a•c .:'. VIL UNDER DISPENSER CONTAINMENT CONSTRItcrION TYR1.SI GLE WALL i DOUBLE WAIL 133.NO MSPENSRRS 0 9R.NONE ON CONSTRUCTION MAMIAL .STEEL N.FIBEROLASS CI io.RrmPLA%,nc 099.OTWIR mmilmrnnc :,'•' '.`. ...Vill. CORROSIONPR&mCTIbN: . . :. STEEL O0MIONErT PROTECTION 03.SACRWXIAL ANODE(S) 0 N.NOKER.9ED CURRENT 06.ISOLATMN ••0. IX. APPLICANT91IGNATURB. - CLIMFRCATION: ReareiFy Thal lhb UST nyMem if rompamlbk rellh the hamrdnne.uhuauee N"d Aad ehaml the W.,inalioR provided hmTln h orae,mecum°. AaR to limill cormplimn.,+ifhlegal o alnmenlf. APPLICANT SIGNATURE- DATE "w 2 Zu Z� t APPLICANT NAME(prim) Or1' APPLICANT TIn.F + S `n E z IIPCF UyT•D-V1 Rev.(12IM7)