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i ED PROGRAM CONSOLIDATED FO <br /> UNDERGROUNDSTORAGETANK <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,11,III,IV,and IX below) 430. <br /> ❑ L NEW PERMIT ❑ 3.RENEWAL PERMIT M 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430.. 1 DATE EXISTING UST DISCOVERED: 4301, <br /> s +. <br /> ,,;,.. I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) - - <br /> 1. <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3, <br /> Tower Market#104 <br /> BUSINESS SITE ADDRESS 103. 1 CITY 104. <br /> 192 Lathrop Rd. Lathrop, CA 95330 <br /> 11. TANKDESCRIPTION <br /> TANK ID ,� aso5 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. <br /> 104 Diesel Modem Welding E 1.A STAND-ALONE TANK CoWideompage for each <br /> 2.ONEINA COMPARTMENTED UNIT cuo,psnaaatathemd. <br /> DATE UST SYSTEM INSTALLED 035- TANK CAPACITY IN GALLONS 436_ NUMBER OF COMPARTMENTS IN THE UNIT 437. <br /> 1945 12,000 1 <br /> III:'TANK USE AND CONTENTS <br /> TANK USE ® Ia.MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ Ic.AVIATION FUELING 439. <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(icxiii sUsed 00) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§2528L5(c)] <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99 OTHER(Specify): 439x. <br /> CONTENTS PETROLEUM: ❑ Ia REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440. <br /> N 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440a <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUM(Specify): 4406. <br /> w,.., IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL E 2.DOUBLE WALL ❑ 95 UNKNOWN _ 443. <br /> PRIMARY CONTAINMENT N 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): _444a <br /> SECONDARY CONTAINMENT [11.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. <br /> ❑ 90.NONE ❑ 95.UNKNOWN N 99.OTHER(Specify): Steel Clad W/Fiberitlass reinforced plastic 065% <br /> OVERFILL PREVENTIONI.AUDIBLE&VISUALALARMS 2.BALLFLOAT N 3.FILL TUBE SHUT-OFF VALVE 452. <br /> E] 4.TANK MEETS REQUIREMENTS ITOR EXEMPTION FROM OVERFILL PREVENTION E MPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑ 1.SINGLE WALL N 2.DOUBLE WALL ❑ 99.OTHER 460. <br /> SYSTEM TYPE N 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3) 458. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4Na. <br /> SECONDARY CONTAINMENT ❑ 1.STEEL E 4.FIBERGLASS ❑ 8.FLEXIBLE O 10.RIGID PLASTIC 4646. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTTER(Specify):_ _464c. <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE N 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644. <br /> . VI. VENT,VAPORRECOVERY(VR) AND RISER%"FII L PIPE"PIPING CONSTRUCTION' <br /> VENT PRIMARY CONTAINMENT ❑ I.STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4464] <br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC N 90.NONE ❑ 99.OTHER(Specify): 44nf: <br /> VR PRIMARY CONTAINMENT ❑ L STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [399.OTHER(Specify): <br /> 44g. <br /> L <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC N 90.NONE ❑ 99.OTHER(Specify): 4641, <br /> 464h1. <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL N 90.NONE _ 464` <br /> RISER PRIMARY CONTAINMENT E 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC [190.NONE El99.OTHER(SPecf5')t 46414641. <br /> . <br /> RISER SECONDARY CONTAINMENT ❑ I.STEEL [14.FIBERGLASS El III RIGID PLASTIC E 90.NONE ❑ 99.OTHER(Specify): 464k]. <br /> FILL COMPONENTS INSTALLED E L SPILL BUCKET N 3.STRIKER PLATFJBOTTOM PROTECTOR E 4.CONTAINMENT SUMP <br /> VIL UNDER DISPENSERCONTAINMENT(UDC) <br /> CONSTRUCTION TYPE N 1.SINGLE WALL El 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90 NONE 4_ <br /> CONSTRUCTION MATERIAL ❑ 1 <br /> STEEL ❑ 4.FIBERGLASS E 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 44696. <br /> VIII. CORROSION`PROTECTION_ <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 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"I[com liance with 1 al requirements. <br /> � 470. <br /> APPLICANT SIGNATURE DATE $/22/2009 <br /> APPLICANT NAME(print) Paul Chevalier471. APPLICANT TITLE Maintenance Mana 472. <br /> UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org <br />