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ED PROGRAM CONSOLIDATED FOP* UNDERGROUND STORAGE TANK o\ I I• OPERATING PERMIT APPLICATION-TANK INFORMATION (OnefotmperUST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,l[111,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: 430. 1 DATE EXISTING UST DISCOVERED: 430? I FACILITY INFORMATION FACILITY ID k(Agency Use Only) 11. BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3_ Tower Market#104 BUSINESS SITE ADDRESS 103. 1 CITY IN. 192 Lathrop Rd. Lathrop, CA 95330 IL TANK DESCRIPTION TANK ID t! / OG /,(/ 432- TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434 104- eg eSf� Modem Welding N LA STAND-ALONE TANK C.,Ieteooepegefuread ❑ 2.ONEINA COMPARTMENTED UNIT eomi,=m tinthewa. DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. 1995 20,000 1 III. TANK USE AND CONTENTS TANK USE N 1..MOTOR VEHICLE FUELING ❑ If.MARINA FUELING ❑ 1,AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Iad uu ou) ❑ S.EMERGENCY GENERATOR FUELIHsC425281.5(,)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439. CONTENTS PETROLEUM: N Ia.REGULAR UNLEADED ❑ 1c.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 449. ❑ 3.DIESEL ❑ 5.MT FUEL ❑ 6.AVIATION GAS ❑_8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL N 2.DOUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT N 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 694 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Speeify): 444• SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ NONE ❑ 95.UNKNOWN ®99.OTHER(Specify): Steel Clad W/Fib lass reinforced plastic 445. OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALLFLID N 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS RE UIREMENTS flbR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION � „ PIPING CONSTRUCTION ❑ 1.SINGLE WALL N 2.DOUBLE WALL ❑ 99.OTHER 469. SYSTEM TYPE N L PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR 42635(.)(3)] 458. PRIMARY CONTAINMENT ❑ L STEEL N 4.FIBERGLASS ❑ 6.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. SECONDARY CONTAINMENT ❑ L STEEL N 4.FIBERGLASS ❑ &FLEXIBLE ❑ 10.RIGIDPLASTIC 4646. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464, PEINGlfURBINE CONTAINMENT SUMP TYPE N 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644. VI. VENT,VAPOR RECOVERY (VR)AND RISER/.FILL PIPE'PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ L STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): g464I. VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC N 90.NONE ❑ 99.OTHER(Specify): 46gf 44"f VR PRIMARY CONTAINMENT ❑ L STEEL N 4.FIBERGLASS ❑ HI RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): q4", VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC N 90.NONE ❑ 99.OTHER(Specify): g464h. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL N 90.NONE �4t RISER PRIMARY CONTAINMENT N L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4611' -_. 464i1. RISER SECONDARY CONTAINMENT ❑ L STEEL El 4.FIBERGLASS ❑ 10.RIGID PLASTIC N 90.NONE El99.OTHER(Specify): 4�j: FILL COMPONENTS INSTALLED N 1 SPILL BUCKET N 3 STRIKER PLATEBOTTOM PROTECTOR N 4.CON FAINMENT SUMP 951 VIL UNDER DISPENSER CONTAINMENT'(UDC) CONSTRUCTION TYPE N I SINGLE WALL, ❑ 2 DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469x. __..-.. ._.... __ ._ .......... .....-----___---------.. .__- __ _....__.__ __- -- __._.... _.-._. CONSTRUCTION MATERIAL ❑ i.STEEL EI 4.FIBERGLASS N 10 RIGID PLASTIC El 99.OTHER(Specify) 4696. VIII. CORROSION`PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448, IX. APPLICANTSIGNATURE 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 11 com liance ' li legal re uirements. APPLICANT SIGNATURE &,t DATE $/22/2009 470 APPLICANT NAME(print) Paul Chevalier 411. APPLICANT TITLEMainM aIz UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org