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2 An <br /> LTMFEED PROGRAM CONSOLIDATED FO <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per DsT) <br /> TYPE OF ACTION {Check ow i(cm vmlq. For u LIST clasurc or removal,complete only this section and Sections 1,11,111,11;mrd LX below) 430. <br /> ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL 4306 <br /> DATE UST PERMANENTLY CLOSED: 430r DATE EXISTING UST DISCOVERED: <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) - - <br /> BUSI 4ESS NAME(&mne as Facility None or DBA-Doing Business As) <br /> My Mini Mart <br /> BUSINESS SITE ADDRESS 103. CITY 104' <br /> 1756 Wilson Way Stockton <br /> 11 TANK DESCRIPTION <br /> TANK ID# 432. TANK MANUFACTURER <br /> 433. TANK CONFIGURATION:THIS TANK IS 434 <br /> Prepared Modem Building ❑ omp <br /> 1.A STAND-ALONE TANK Clete ono Page fora h <br /> 91 SUL#1 Company M 2.ONE IN A COMPARTMENTED UNIT rnmpmme0t;o a'-u <br /> DATE UST SYSTEM INSTALLED 43s. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. <br /> 7. 14 at,1 '� 2 <br /> III. TiNK USE AND CONTENTS <br /> TANK USE M Is,MOTOR VF.HTCT,F MJFT.INC, ❑ Ih.MARINA R IIF.T MG ❑ le.AVIATION FIIF.T.ING 439. <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(j.,J ea uaed ci0 ❑ 5.EMERGENCY GENERATOR FUEL[Hsc§25281.5(0)1 <br /> __ F-16 OTHER GENERATOR FUEL _ ❑ 95.UNKNOWN [1 99.OTHER(Specify): e9a. <br /> CONTENTS PETROLEUM: SaAR <br /> .REGUL_Uia EADED ❑ 1c.MIDGRADEUNLEADED ® ]h PREMIUM UNLEADED 44a <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 44U <br /> NON-PETROLEUM:❑ 7.U9FDOTT - -OIn,ETHTNGI. <br /> ❑ 11.OTHER NON-PETROLEUM Specify): 4406. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL M 2.DOUBLE WALL ❑ 95.UNKNOWN 443' <br /> PRIMARY CONTAINMENT M 1.STEEL M 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444' <br /> _ ❑ 7.STEEL INTERNAL LINING ❑ 95.UNKNOWN_ O 99.OTHER(Spat$'): ^444a. <br /> SECONDARY CONTAINMENT M 1.STEEL M 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE UNER ❑ 7.JACKETED aas. <br /> ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER(Spaify): ass <br /> OVERFILL PREVENTION ® 1.AUDIBLE&VISUAL ALARMS M 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452 <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTIONEl1,.SINGLE WALL M 2.- DOUBLE WALL ❑ 99.OTHER _ 4611. <br /> SYSTEM TYPE _ _ M 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION L34.SAFE SUCTION[23 cc2§2636(ax3)] 458. <br /> PRIMARY CONTA_INMENT ❑ L STEEL M 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. <br /> ❑ 90,NONE ❑ 95,UNKNOWN ❑ 9_9.OTHER(Specify): 464'' <br /> SECONDARY CONTAINMENT El 1.STEEL M 4.FIBERGLASS El8.FLEXIBLE [110.RIGID PLASTIC 4646. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(SPecify): .4640. <br /> _ --_.___- _ _._........_-. _. __. 4644 <br /> PIPINGITURBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE <br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4 <br /> ___ <br /> VENT'SECGNUARY CON'1'A1NMEN'I LJ 1.STEEL U 4.FIBERGLASS LJ 10.RIGID PLAS'T'IC LJ 90.NONE LJ 99.(yrHER(Sp=4): 464n, <br /> 444 <br /> VR PRIMARY CON--TAR-4ME <br /> NT ❑ L STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [399.OTHER(Specify): 4= <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Speedy): 4661. <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE <br /> - 464i <br /> RISER PRIMARY CONTAINMENT ❑ 1.S'IELL ❑ 4.EWLRGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Spmuy). �k;- <br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464k1.,- <br /> FH,L COMPONENTS INSTALLED M 1.SPILL BUCKET M 3.STRIKER PLATEBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 4351-0. <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRT iCTION TYpR __ M I SINGLE WALT. ___ ❑ 2.DOUBIF W.4T 1, ❑ 3.NO DISPF:NSF.RS ❑ TIF. 46%. <br /> CONSTRUCTION MATERIAL M L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 99.OTHER(Specify) �e ; <br /> VIII, CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES ❑ 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 pro ed herein is true, <br /> aceurate and In full com Bance with le m uirements. <br /> 470 <br /> APPLICANT SIGNATURE DATE 7/8/2009 <br /> UPCF UST-B Rev.(1212007)-113 wwmunitims.org <br />