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r • UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections L 11,111,1V,and IX beloly) 410_ ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ® 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 0 S.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4Ir- I DATE EXISTING UST DISCOVERED: 4108. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ _ r. BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. Tower Market# 886 BUSINESS SITE ADDRESS 103. CITY IN 1434 W. Yosemite Ave. Manteca,CA 95337 II. TANK DESCRIPTION TANK ID# 02, TANK MANUFACTURER 431- TANK CONFIGURATION:THIS TANK IS 414. 886-Prem Modem Welding ® LA STAND-ALONE TANK CC.pleteo<p.ge fa e.h ❑ 2.ONE M A COMPARTMENTED UNIT -W--t in Ne-mt. DATE UST SYSTEM INSTALLED 435, TANK CAPACITY IN GALLONS 43a NUMBER OF COMPARTMENTS IN THE UNIT 437 C1.0- 1991 8,000 1 III. TANK USE AND CONTENTS TANK USE ® Ia.MOTOR VEHICLE FUELING ❑ I b.MARINA FUELING ❑ Ic.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes WN Oil ❑ 5.EMERGENCY GENERATOR FUEL[HSC$3529 I.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(SpcEify): 43%. CONTENTS PETROLEUM. ❑ Ia.REGULAR UNLEADED ❑ Ic MIDGRADE UNLEADED ® Ib.PREMIUM UNLEADED 446 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ____NON-_______-____-❑ HE _S.PETROLEUM BLEND FUEL 0 9.OTR PETROLEUM(Specify):_ 440a. PETROLEUM:❑ 7.USED 0[L ❑ METHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL (@ 2.DOUBLE WALL ❑ 95.UNKNOWN 443. .__..._- ________. ___.___ ...__...._ ...._.._ _ __._. _."_....__._.__ PRIMARY CONTAINMENT ® I.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99 OTHER(Specify): 4Jae SECONDARY CONTAINMENT ❑ I.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95 UNKNOW_N ®99.OTHER(Specify}Steel Clad W/Fibergles5 reinforced plastic 445.. _...... _ .__.-.._-.._ OVERFILL PREVENTION ® 1.AUDIBLE&VISUAL ALARMS C1 2.BALL AT FLO ❑ 3.FILL TUBE SHUT-OFF VALVE 452 ❑ 4.TANK MEETS RE UIRF.MFNTS FOR FXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ L SINGLE WALL 19 2 DOUBLE WALL ❑ 99.OTHER_ __ 460. - .__._- ____-_.__._._._ .__".".. .........._ . . __ _..._. . _ . _ _ _ _... SYSTEM ® 1.PRESSURE _O,2 GRAVITY .O 3.CONVENTIONAL SUCTION- O 4,SAFE SUCTION[n CCR;2636(.)(3)1_ 458,_ PRIMARY CONTAINMENT ❑ L STEEL ® 4 FIBERGLASS [:I 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify); 46aa. SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC a646. ❑ 90.NONE ❑ 95,UNKNOWN ❑ 99.OTHER(SPeeifo 464a .- ._-____ _- PIPINGICURBINE CONTAINMENT SUMP TYPE ® I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4fi46- VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ l0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): ._.______. ........__..__ ............. _______-..... . .....__..._. .._____._. VENT SECONDARY CONTAINMENT ❑ I STEEL ❑ 4 FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99 OTHER(Specify): 46gr VR PRIMARY CONTAINMENT ❑ 1.91 EEL 1814 FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER 4641 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4 FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): '46 jh __.__.._..._ _..._____.... ....._..___._._ _..........._ _........."---..... VENT PIPING TRANSITION SUMP TYPE ❑ 1 SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 464' ._."._.._..."... ._.__._. ..._._._._._-.__ _-_____ -ala, RISER PRI MARY CONTAINMENT ® I.STEEL ❑ 4 FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46,1 .._____..._... . ____-__ _...___ONE[1 ._4_" RISER SECONDARY CONTAINMENT ❑ 1 STEEL ❑ 4 FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 46441 FILL COMPONENTS INF. STAR D ® LSPILL BUCKET ® 3 STRIKER PLATE/BOTTOM PROTECTOR ® 4.CONTAINMENTSUMP VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL _® 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469.. CONSTRUCTION MATERIAL ® I STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) qb�; VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. it IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate,and in full com lis ce with legal requirements. APPLICANT SIGNATURE U/,� DATE 11/1/2011 470 APPLICANT NAME(print) Paul Chevalier 471. APPLICANT TITLE Maintenance Manager 472. UPCF UST-B Rev.(12/2007)-IPS www.unidocs.org