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AMR <br /> D PROGRAM CONSOLIDATED FOVW <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per1,3).0. <br /> TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections I.II,III,IV,and LY below) <br /> ® 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430& 1 DATE EXISTING UST DISCOVERED: 430b. <br /> L FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) _ _ I. <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> Food Mart Gasoline <br /> BUSINESS SITE ADDRESS 103• 1 CITY 104. <br /> 2185 Fremont Street Stockton, CA. 95205 <br /> II. TANK DESCRIPTION <br /> TANK ID# 432• TANK MANUFACTURER 433• TANK CONFIGURATION:THIS TANK IS 434. <br /> 3 Modern Welding ❑ 1.A STAND-ALONE TANK Complete one page for each <br /> ® 2.ONE IN A COMPARTMENTED UNIT compaM cnt in the unit. <br /> DATE UST SYSTEM INSTALLED 435• TANK CAPACITY IN GALLONS 436• NUMBER OF COMPARTMENTS IN THE UNIT 437. <br /> 2004 5,000 3 <br /> M. TANK USE AND CONTENTS <br /> TANK USE ® la MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439. <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(talu&s Used oil) ❑ 5.EMERGENCY GENERATOR FUEL 1HSc g2s2s1.5(c)) <br /> ❑ <br /> 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439& <br /> CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ la MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440. <br /> ® 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440& <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUM(Specify): "Ob. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443. <br /> PRIMARY CONTAINMENT ® 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify} 444& <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. <br /> ____ ❑ 90.NONE _ ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445& <br /> OVERFILL PREVENTION ® 1.AUDIBLE&VISUAL ALARMS ® 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 99.OTHER 460. <br /> SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION [1 4.SAFE SUCTION 123 CCR J2636(a)(3)] 458. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464x. <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646• <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644. <br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464x' <br /> 464e1. <br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464L <br /> 4641. <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 4648 <br /> !KA 1. <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE El99.OTHER(Specify): 464h. <br /> _ 464hL <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 4641. <br /> RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 9o.NONE ❑ 99.OTHER(Specify): 4643' <br /> "I. <br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464k. <br /> 464k1. <br /> FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a-c-c. <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469x. <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ® 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 46% <br /> 469c. <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION aas. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, <br /> accurate,and in full compliance with legal requirements. <br /> 1PPLICANT SIGNATURE DATE ©� S C) t 470 <br /> ICANT NAME(Print) APPLICANT TITLE 472_ <br /> � ) Ram Rattan Operator <br /> B Rev.(12/2007)-1/2 www.unidoes.orgkh yy <br /> 1 <br />