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Ah AM <br /> IFIED PROGRAM CONSOLIDATED FOIM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One:: <br /> One form per UST) <br /> TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections I,A III,IV,and IX below) a3o. <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: 430a DATE EXISTING UST DISCOVERED: RnpilMn 430b. <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) 1. <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> Food Mart Gasoline <br /> BUSINESS SITE ADDRESS lo3• I CITY ENVIRONMENTAL HEALTH loa. <br /> 2185 Fremont Street Stockton, CA. 95205 PERMIT/SERVICES <br /> IL TANK DESCRIPTION <br /> TANK ID# \T / a3z TANK MANUFACTURER 433• TANK CONFIGURATION:THIS TANK IS 434. <br /> O i I,/v"' Modern Welding ❑ 1.A STAND-ALONE TANK Complete one page for each <br /> ® <br /> 2.ONE IN A COMPARTMENTED UNIT compartment in the une. <br /> DATE UST SYSTEM INSTALLED 435. <br /> TANK CAPACITY IN GALLONS 436• NUMBER OF COMPARTMENTS IN THE UNIT 437. <br /> 2004 5,000 3 <br /> III. TANK USE AND CONTENTS <br /> TANK USE IR la MOTOR VEHICLE FUELING ❑ 1 b.MARINA FUELING ❑ lc.AVIATION FUELING 439. <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Include.Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] <br /> _ ❑ 6.OTHER GENERATOR FUEL _ ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439& <br /> CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ ]c.MIDGRADE UNLEADED ® lb.PREMIUM UNLEADED 440• <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440x. <br /> NON-PETROLEUM: 7.USED OIL ❑ 10.ETHANOL <br /> ❑ <br /> 11.OTHER NON-PETROLEUM(Specify): 440b. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 4a3. <br /> PRIMARY CONTAINMENT ® 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444x. <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. <br /> _ ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(specify): 445x. <br /> OVERFILL PREVENTION ® 1.AUDIBLE&VISUAL ALARMS ® 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE ase. <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 ❑ 4.SAFE SUCTION[23 CCR§2636(ax3)] _ <br /> 458. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. - <br /> --- <br /> 64•_ ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a. <br /> SECONDARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. <br /> ❑ 90.NONE _ ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. <br /> PIPING/1'URBINE CONTAINMENT SUMP TYPE ® L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464(. <br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PR34ARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [199.OTHER(Specify): 4640• <br /> -• - _ 464e1. <br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464f. <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464g- <br /> 464 1.- <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): ' <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 ❑ 90.NONE ❑ 99.OTHER(Specify):- 464il. <br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL [1 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464L <br /> 464k1. <br /> FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c. <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 4698. <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ® 10.RIGID PLASTIC ❑ 99.OTHER(Spwify) �. <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448_ <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided heroin is true, <br /> accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE �- 1 DATE 11/29/2012 470. <br /> APPLICANT NAME(Print) Jogin er Lal 471• APPLICANT TITLE Operator/Owner , 472. <br /> UPCF UST-B Rev.(12/2007)-1/2 www.unidoes.org <br />