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'TN IFIED PROGRAM CONSOLIDATED FW44 UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per US TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,11,111,IV,and IX below) 430 ❑ I.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:unknown 430. DATE EXISTING UST DISCOVERED:unknown 43ob I. FACILITY INFORMATION FACILITY IDN(Agency Use Only) - - 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 San Joaquin County Human Services Agency Building BUSINESS SITE ADDRESS 103CITY 104 145 South Sutter Street Stockton II.TANK DESCRIPTION TANK IDN unknown 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 uknown ❑ I.ASTAND-ALONE TANK [12.ONE IN A COMPARTMENTED UNIT. Co Ide one •e for nch com mnt in the mft. DATE UST SYSTEM INSTALLED 035 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 unknown unknown unknown III.TANK USE AND CONTENTS TANK USE ❑ 1a.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includm Wei Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§2528L5(c)] ❑ 6.OTHER GENERATOR FUEL ® 95.UNKNOWN ❑ 99.OTHER (Specify): 439. CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 44o ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): unknown moa NON-PETROLEUM.❑ 7.USED OIL ❑ 10.ETHANOL ❑ II.OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ L STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING 10 95.UNKNOWN ❑ 99.OTHER (Specify): 444e SECONDARY CONTAINMENT ❑ L STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ® 95.UNKNOWN ❑99.OTHER S ci 445e OVERFILL PREVENTION ❑ 1.AUDIBLE&.VISUAL ALARMS ❑ 2.BALL FLOAT U 3.FILL TUBE SHUT-OFF VALVE 452 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE-WALLED [12.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR§2636(a)(3 458 PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ &FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHERS ify): 4Ma SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(S ify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ I0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 4640 VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4Mf 464n VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464" 464.1 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID P07ST_1_C____0 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4641 RISER PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.0THER(Specify) 4641 464'1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ HI RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 464k1 FILL COMPONENTS INSTALLED ❑ L SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469. CONSTRUCTION MATERIAL ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER 5 eci 4691" VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448' IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system is compatible with the hamrdous substance stored and that the information provided herein is true,accurate, and in full compliance with legal requirements. 470. APPLICANT SIGNATURE (n_ /J 'p DATE Z �O APPLICANT NAME(print) 47L APPLICANT TITL 472, UPCF UST-B-1/2 Rev.(12/2007)