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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section 1,II,iD, and below bl6 ❑ 1.NEW PERMIT 0 3.RENEWAL PERMIT ❑ 5. FOk I T (Jj ' )�" 6.TEMPORARY UST CLOSURE [17.UST PERMANENT CLOSURE ON SITE ❑ 8. T OV �` `' DATE UST PERMANENTLY CLOSED: Goa DATE EXISTING UST DISCOVERED: -'c'-r 4XI, I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 BUSINES NAME( as ACUITY NAME or DBA-Doing Business As) 3 IL �2.��Aj C61V 4tjQl SAN JOAQUiN COUNT!' BUSINESS SITE AD Im CITY ZiALT!; q,'t}3TMENp[ Im _r • ric 4 P {NIRn�fyS¢ cy� 1r3.3C. IL TANK DESCRIPTION TANKIC" y� �.y� 432 TANK MANUFACTURER 4" ETANIK rTAANKK CONF(GURAT[ON: T=TANKI3 434 ONE IN A Iyrt. COMPARTMENTED UNIT. Cam lm orn Pnefor nub mm mmmt in the unit. DATE U$T SY$'�M INSCALLED +35 TANKCArACITY IN GALLONS 436 NUMBER OF COMP TMENTS IN THE UNIT +n S �6 1 Y 9 IIIA.TANK USE AND CONTENTS TANK USE MOTOR VEHICLE FUELING Q tb.MARINA FUELING ❑ Ic.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑4.HAZARDOUS WASTE(InrJudv l W) Q 5,EMERGENCY GENERATOR FUEL W§252aL5(a)I 116.OTHER GENERA FUEL Q 95.UNKNOWN ❑ 99.OTHER( 'fy): 43% CONTENTS PETROLEUM: LAR UNLEADED El 1c.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 .DIESEL ❑ 5.JET FUEL 0 6.AVIATION GAS L3 8.PETROLEUM BLEND FUEL ❑ 9.01HER PETROLEUM S 440n NON-PETROLEUM:❑ 7.USED OIL Q 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM b4ab IV. TANK CONSTRUCTION TYPE OF TANK ❑ L SINGLE WALL 2.DOUBLE WALL 0 95.UNKNOWN µ3 PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 4N 7.STEEL+INTERNAL LINING 095.UNKNOWN 099.0THER S 4W SECONDARY CONTAINMENT Q L STEEL ❑3.FIBERGLASS6.EXTERIOR MEMBRANE ER Q 7.JACKETED 445 fT 90. NE ❑ 95.UNKNOWN 99.OTHER S eci ase OVERFILL PREVENTION .AUDIBLE&VISUAL ALARMS U 2.BALL FLOAT 6113.FILL TUBE SHUT-0FF VALVE 452 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/NVASTE PIPING CONSTRUCTION PIPING CONSTRUCTION LSINGL&WALLED UBLE-WALLED Q99.OTHER bfd SYSTEM TYPE &A-PRESSURE ❑ 2.GRAV TTY ❑ 3.CONVENTIONAL SUCTION 4.SAFE SUCTION(U CCRIM 4158 PRIMARY CONTAINMENT Q L STEELW.4-FIBERGLASS 0 S.FLEXIBLE ❑ 10.RIGID PLASTIC 16t 0 90.NONE 0 95.UNKNOWN Q 99.OTBER(Speeify): 964 SECONDARY CONTAINMENT 0 I.STEEL ELE 0 10.RIGID PLASTIC 4616 ❑ 90.NONE Q 95.UNKNOWN ❑ 99.OTHER(Specify): 161e PIPINGffURBINE CONTAINMENT SUMP TYPE LE WALL Q 2.DOUBLE WALL ❑ 90.NONE bbae VI.VENT,VAPOR RECOVERY(VR)AND RISER!FILL PIPE PIPING CONSTRUCTION ® VINT PRIMARY CONTAINMENT Fert.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 46b VENT SECONDARY CONTAMMENT _ 1.STEEL 4.FIBEROT.AS.4 �e1 O ❑ l0.RKTm PLASTIC 90.NONE 099.OTHER(Specify) 461[ VR PRIMARY CONTAINMENT �f LSTFRL 4.FIBERGLA93 10.RIGID 4"n PLASTIC 90.NONE ❑ 99.OTHER(Specify) 4618 O VR SECONDARY CONTAINMENT LS ® 4.FIBERG[,ASS ❑ 10.RIGID PLASTIC 464a1 ❑ 90.N ❑ OTHER(Sptxify) 4606 69h1 O VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOABLE WALL .NONE - 4Mi. mbbK PRIMARY CONTAINMENT i.STEELU 4.FIBERGLASS u 10.0001)PLASTIC LY 90.NONE Lj 99.OTHER(Sp-w 460j RISER SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER 1 (Specify) 4614 FR,LCOMPONEN[9INSTALLED itl 451tc 46. .l.3PB.L BUCKET 3.STRIKER PLATE/BO'1'I'OM PROTECTOR 4.CONTAINb¢N1'SUMP UNDER DISPENSER:f`9X TAINMENT.(UDC) CONSTRUCTION TYPE GLE WALL .ABLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 46A CONSTRUCDON MATERIALLVA.STEEL Ll 4.FIBERGLASS �0 10.RIGID PLASTICU W.OTHERS 4696c VDL CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES) ❑ 4.IMPRESSED CURRENTSOLATION 44L IX. APPLICANT SIGNATURE CERTffICATTON: [certify that this UST system is compedble with the hazardous substance stored and that the information provided herein is true,accurate, and in full compliance with Iremems. APPLICANT SIGN ' 06. APPLICANT NA pont) 47E APPLICANT TrnX4M III"UST-B-»3 completed Re,(1212007)