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IFIED PROGRAM CONSOLIDATED F011ed <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION- TANK INFORMATION (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) 430. <br /> El 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.• DATE EXISTING UST DISCOVERED: 4306. <br /> L FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) D C 3 <br /> Food Mart Gasoline C <br /> BUSINESS SITE ADDRESS 103. <br /> Cr1y ENVIRONMENTAL HEALTH <br /> 2185 Fremont Street Stockton, CA. 95205 - <br /> IL TANK DESCRIPTION <br /> TANK 19# ( �"`� 432• TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. <br /> " 113 5"(,,-1 + Modern Welding ❑ 1.A STAND-ALONE TANK Complete one page for each <br /> DATE UST SYSTEM INSTALLED 435. ® 2.ONE IN A COMPARTMENTED UNIT compartment in the ani. <br /> TANK CAPACITY IN GALLONS 436• NUMBER OF COMPARTMENTS IN THE UNIT 437. <br /> 2004 5,000 <br /> 3 <br /> III. TANK USE AND CONTENTS <br /> TANK USE ® la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439. <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Iiwludea Used oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99-OTHER(Specify): 439a <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): 440a <br /> NON-PETROLEUM:❑ 7.USED OIL U 10.ETHANOL -- <br /> ❑ 11.OTHER NON-PETROLEUM(Specify): 4406. <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 <br /> [17.STEEL+INTERNAL LINING El 95.UNKNOWN ❑ 99.OTHER(Specify): 444a 4".SECONDARY CONTAINMENT ❑ L STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED us. <br /> _ ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a <br /> OVERFILL PREVENTION ® 1.AUDIBLE&VISUAL ALARMS ® 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE <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. MR 460 <br /> SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR 459. <br /> PRIMARY CONTAINMEIIT ❑ 1.STEEL [ §2636(ax3)) <br /> ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC aha. <br /> _ ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464x. <br /> SECONDARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify)- 464c <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE ® L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE aead. <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): 464e. <br /> -- -- -- - <br /> 1§4L <br /> VENT SECONDARY CONTAINMENT <br /> ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464f. <br /> VR PRIMARY CONTAINMENT 46411. <br /> ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464g. <br /> 464 1• <br /> VR SECONDARY CONTAINMENT <br /> ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464h. <br /> VENT PIPING TRANSITION SUMP TYPE 111.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 4641 <br /> RISER PRIMARY CONTAIIIMENT ❑ 1.STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464j. <br /> _RISER SECONDARY CONTAINMENT �1• <br /> ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 4"k. <br /> FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ❑ 3.STRIKER PLATEBOTTOM PROTECTOR [145la-cac4.CONTAINMENT SUMP 4 . <br /> . <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE _ ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a. <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ® 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696• <br /> F-1, 469c. <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 herein is true, <br /> accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATUREI DATE 11/29/2012 4 <br /> 70. <br /> APPLICANT NAME(print) Joglri er Lal 471• APPLICANT TITLE Operator/Owner 4n. <br /> UPCF UST-B Rev.(12/2007)-1/2 www.unidocaorg <br />