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LIED PROGRAM CONSOLIDATED FOR <br /> UNDERGROUNDSTORAGETANK M^ <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/,!I!,/I;and IX below) <br /> 430. <br /> ❑ L NEW PERMIT ❑ 3.RENEWAL PERMIT ® 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE [_1 7.UST PERMANENT CLOSURE ON SITE C] 8.UST REMOVAL 430b. <br /> DATE UST PERMANENTo <br /> LY CLOSED: DATE EXISTING UST DISCOVERED: <br /> 1. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) FEI <br /> 3. <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) <br /> Tower Market#104 104. <br /> BUSINESS SITE ADDRESS I03 CITY <br /> 192 Lathrop Rd. Lathrop, CA 95330 <br /> IL TANK DESCRIPTION <br /> ��] �(�'/_� 432. TANK MANUFACTURER 433 TANK CONFIGURATION THIS TANK IS 434. <br /> TANK ID N QSQ o IU ® L A STAND-ALONE TANK Comply ooe page t mch <br /> 1419 East Modem Welding ❑ 2.ONEINA COMPARTMENTED UNIT compatmwtmtbeuaa. <br /> 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. <br /> DATE UST SYSTE SfA �D 1 <br /> 5 I "( 20,000 <br /> III. TANK USE AND CONTENTS <br /> TANK USE } M Ia.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ I,AVIATION FUELING <br /> 419. <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(lacludes Uw Oa) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(a39a. <br /> ❑ 6.OTHER GENERATOR I UEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): �0 <br /> CONTENTS PETROLEUM: N Ia.REGULAR UNLEADED ❑ Ic.MIDGRADEUNLEADED ❑ lb.PREMIUM UNLEADED <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS I0a <br /> _ ❑ 8.PETROLEUM BLEND FUEL _❑ 9 OTHER PETROLEUM(Specify): <br /> NON-PETROLEUM:(D7.USED OIL ❑ 10.ETHANOL 440b. <br /> ❑ I I.OTIIER NON-PETROLEUM(S ,cif <br /> n5 .. IV. TANK CONSTRUCTION <br /> +siR'AVSt l9jn.¢.a:. 443. <br /> TYPE OF TANK _ O-L SINGLE WALL_ ® 2.DOUBLE WALL LJ 95.UNKNOWN -.__._-.-_--- 4a4-- <br /> PRBv1ARY CONT ®AINMENT 1.STEEL El3.FIBERGLASS ❑ 6.INTERNAL BLADDER a4a <br /> C17.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 445. <br /> SECONDARY CONTAINMENT ❑ L STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 645a <br /> ❑ 90.NONE Cl 95.UNKNOWN ®99.OTHER(Spxify): SCeel Clad W/Fiberglass reinforced plastic 45z <br /> OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT ® 3.FILL TUBE SHUT-OFF VALVE <br /> ❑ 4.TANK MEETS REQUIREMENTS OREXEMPTION FROM OVERFILL PREVENTIONE UIPMETJT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> 460. <br /> PIPING CONSTRUCTION_❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 99.OTHER 458. <br /> SYSTEM TYPE ® 1 PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAES SUCTION[23 CCR§2636(aX3)] <br /> PRIMARY CONTAINMENT ❑ 1.STEEL ® 4-FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464a. <br /> ❑ 90.NONE [195.UNKNOWN El 99.OTHER(Specify): 464b. <br /> SECONDARY CONTAINMENT ❑ L STEEL W 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 46ac. <br /> ❑ 90.NONE ❑ 95 UNKNOWN _❑ 99 OTHER(Spmfy) - 464d - <br /> PIPING/fURBINE CONTAINMENT SUMP TYPE ® 1 SINGLE WALL El2 DOUBLE WALL ❑ 90 NONE <br /> VI. VENT,VAPOR RECOVERY"I AND'RISER/'FILL PIPEPIPING'CONSTRUCTION; 464e. <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464e1, <br /> 464f. <br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 4648. <br /> 464g. <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(SI>ecify): 4 � <br /> VR SECONDARY CONTAINMENT Cl I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): . <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.IX)UBLE WAIL ® 90.NONE n6a1 <br /> RISER PRIMARY CONTAINMENT ® I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46411. <br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.TBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.GTH{ER(Specify): 464kI.. <br /> _ 45 Tac <br /> FILL COMPONENTS INSTALLED ® 1 SPILL BUCKET ® 3 STRIKER PLATF/BOTI'OM PROTECTOR ® 4-CONTAINMEM SUMP <br /> s VII. UNDER DISPENSER CONTAINMENT (UDC) '.` <br /> 69a <br /> CONSTRUCTION TYPE ® 1 SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3 NO DISPENSERS ❑ 90.NONE _ _ <br /> .-._-__-_ .__.- - 4696. <br /> CONSTRUCTION MATERIAL ❑ L STEEL El4.FIBERGLASS ® 10.RIGID PLASTIC ❑ 99.OTHCR(Specif') 469c. <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION El 2.SACRIFICIAL ANODE(S) [1 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. <br /> IX. APPLICANT SIGNATURE' <br /> CERTIFICATION: 1 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 com Iiane Hit I al re uireme-ts. 420 <br /> APPLICANT SIGNATURE DATE 8/22/2009 <br /> 472. <br /> APPLICANT NAME(prin[) PBUI Chevalier <br /> a7i APPLICANTTITLE Maintenance M <br /> UPCF UST-B Rev.(1212007)-1/2 www.unidoes.org <br />