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of <br /> ED PROGRAM CONSOLIDATED FOR W <br /> UNDERGROUND STORAGE TANK �WU1 <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) <br /> 430. <br /> TYPE OF ACTION (Check one item only. Fora UST closure orremoval,complete only this section and Sections05.CHANGE OF INFORMATION <br /> El 1.NEW PERMIT ElF <br /> 3.RENEWAL PERMIT <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOOSU DANSrFE ATE EXISTING US[1 8.UOVREMOVAL 43ob. <br /> DATE UST PERMANENTLY CLOSED: <br /> 1. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) <br /> 3. <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) <br /> Tower Market#104 <br /> 104. <br /> BUSINESS SITE ADDRESS 103" CITY <br /> 192 Lathrop Rd. Lathrop, CA 95330 <br /> IL TANK DESCRIPTION <br /> �. �:. <br /> 432. TANK MANUFACTURER a33. TANK CONFIGURATION:THIS TANK IS °34 <br /> TANK ID#� 4566 �q-O ® 1.A STAND-ALONE TANK Complete a=pace for each <br /> 104-PrremJJ Modem Welding ❑ 2.ONE INA COMPARTMENTED UNIT ca��ct i^I1c a°^ <br /> DATE UST SYSTEM INSTALLED <br /> 435. TANK CAPACITY IN GALLONS d36 NUMBER OF COMPARTMENTS IN THE UNIT 431. <br /> 20,000 1 <br /> III. TANK USE AND CONTENTS <br /> TANK USE El MOTOR VEHICLE FUELING El 16.MARINA FUELING ❑ 5. AVIATION FUELING <br /> 439. <br /> El 3. <br /> 3.CHEMICAL PRODUCT STORAGE El 4.HAZARDOUS WASTE(Includes Used oil) LlS.EMERGENCY GENERATOR FUEL[HSC§2528 L5439z <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 440 <br /> CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ® lb.PREMIUM UNLEADED <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> _❑ <br /> S.PETROLEUM BLEND FUEL ❑_9.OTHER PETROLEUM(Specify): <br /> NON-PETROLEUM:❑ 7 USED OIL ❑ 10.ETHANOL 440b <br /> ❑ 11.OTIIERNON-PETROLEUMS cif : <br /> IV. TANK CONSTRUCTION <br /> _TYPE OF T_A_N_K _ ❑_L_SINGI E WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN <br /> IMARY 443. <br /> PRCONTAINMENT ® 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444a <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS Cl 6.EXTERIOR MEMBRANE LONER ❑ 7.3ACKETED a15. <br /> ❑ .NONE ❑ 95.UNKNOWN ®99.OTHER(Specify): Steel Clad W/Fiber lass reinforced plastic 445a <br /> OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT ® 3.FILL TUBE SHUT-OFF VALVE 452' <br /> C14.TANK MEETS RE UIREMENTS OR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT_ <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION ;, '.( <br /> 460. <br /> PIPING CONSTRUCTION ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 99.OTHER <br /> 458 <br /> STEM TYPE ® I.PLl . <br /> SYRESSURE 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION [1 4.SAFE SUCTION in CCR g2636(aX3)1 464. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL IN 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464x. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464b. <br /> SECONDARY CONTAINMENT ❑ L STEEL N 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464c <br /> El90_NONE_-_ [1 95.UNKNOWN _ C399 OTHER(Spec', ) 4644. <br /> PIPINGn URBINE CONTAINMENT SUMP TYPE ® 1 SINGLE WALL ❑ 2 DOUBLE WALL ❑ 90 NONE <br /> VL VENT,VAPOR RECOVERY (VR)'AND,RISER/FILL PIPE PIPING CONSTRUCTION " <br /> 464c <br /> VENC PRIMARY CONTAINMENT El 1.STEEL ® 4.FIBERGLASS El 10.RIGID PLASTIC El 90.NONE ❑ 99.OTBER(Specify): 464c1._ <br /> _ 464(. <br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL. ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 4648, <br /> 4648. <br /> VR PRIMARY CONTAINMENT ❑ 1 STEEL ® 4 FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464gL <br /> h <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ® 90.NONE ❑ 99.OTHER(Specify). 4Nh1. <br /> _ 464i <br /> VENT PIPING TRANSITIONSUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE _ <br /> 464). <br /> RISER PRIMARY CONTAINMENT ® 1.STEEL [34.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464'1" <br /> 464k. <br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464kI <br /> FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ® 4.CONTAINMENT SUMP <br /> VII. UNDER DISPENSER CONTAINMENT (UDC) '' <br /> 469a <br /> CONSTRUCTION TYPE ® I.SINGLE WALL [32_DOUBLE WALL C11 NO DISPENSERS CI90 NONE __ 469ti <br /> CONSTRUCTION MATERIAL ❑ I STECL ❑ 4 FIBERGLASS ® 10 RIGID PLASTIC ❑ 99 OTHER(Specify) 469c. <br /> VIII. CORROSION PROTECTIONr�•, n <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 earn Hance with I at re uirements. <br /> 410. <br /> APPLICANT SIGNATURE DATE 8/22/2009 <br /> 411 412. <br /> APPLICANT NAME(print) Paul Chevalier APPLICANTTITLE Maintenance Manager <br /> UPCF UST-B Rev.(12/2007)-112 www.unidocs.org <br />