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\,,IFIED PROGRAM CONSOLIDATED FOh,_ <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (one farm per uST) <br /> TYPE OF ACTION (Check one item only For a UST ckoure or removal,complete only this section and Sections l!l,/!/,/V,and IX below) +30 <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 <br /> DATE UST PERMANENTLY CLOSED: a3a I DATE EXISTING UST DISCOVERED: 43% <br /> I. FACILITY INFORMATION <br /> FACILITY IDN(Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing 8lariness As) 1 3 <br /> ShelVTesoro 68150 <br /> BUSINESS SITE ADDRESS 101 CITY 104 <br /> 13975 E. Hiway 88 1 - eford <br /> U. TANK DESCRIPTION <br /> TANK ID N 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 <br /> r - STIP 0 LASTAND-ALONE TANK complat �rfat� <br /> 2.ONE IN A COMPARTMENTED UNIT amen M cm ma. <br /> DATE UST SYSTEM INSTALLED 431 TAMC CAPACITY IN GALLONS 434 NUMBER OF COMPARTMENTS IN THE UNIT 437 <br /> 1990 10,000 <br /> I <br /> III. TANK USE AND CONTENTS <br /> TANK USE 0 Is MOTOR VEHICLE FUELING 0 It.MARINA FUELING 0 le.AVIATION FUELING 419. <br /> 13 3.CHEMICAL PRODUCT STORAGE 0 4.HAZARDOUS WASTE(6r;IWn U.w OIh 0 5.EMERGENCY GENERATOR FUEL[HSC§Bn1.5(c)I <br /> 0 6.OTHER GENERATOR FUEL 0 95.UNKNOWN 13 99.OTHER(Speei ): 4394 <br /> CONTENTS PETROLEUM: U Is.REGULAR UNLEADED 0 la MIDORADE UNLEADED 0 Ib.PREMIUM UNLEADED 440. <br /> 3. <br /> ❑ S.JET FUEL 0 6.AVIATION GAS <br /> ... En.PETROLEUM BLEND FUEL 0 9.OTHER PETROLEUM <br /> NON-PETROLEUM:U 7.USED OIL 10.ETHANOL <br /> 0 11.OTHER NON-PETROLEUM(Specify) 4496 <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK 0 1.SINGLE WALL ® 2.DOUBLE WALL 0 95N.UNKNOWw3 <br /> PRIMARY CONTAINMENT _.__. TERN__ __ _.__ _ _ <br /> ® I.STEEL ❑ 3.FIBERGLASS D 66..INTERNAL BLADDER - -44W- <br /> [3 <br /> 7.STEEL*INTERNAL LINING 0 95.UNKNOWN 0 99.0THER(Specify)' ews <br /> SECONDARY CONTAINMENT 0 1.STEEL 0 3.FIBERGLASS - -O 6.EXTERIOR MEMBRANE LINER 0 7.JACKETED M5. <br /> 0 90.NOW 0 95.UNKNOWN 0 99.OTHER(SpwifyY. 44x <br /> OVERFILL PREVENTION 0 1.AUDIBLE&VISUAL ALARMS 0 2.BALL FLOAT 0 3.FILL TUBE SHUT-OFF VALVE 452. <br /> 0.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION E UIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION D 1_SINGLE WALL 0 2.DOUBLE WALL 0 99.OTHER _ __ 460. <br /> SYSTEM TYPE 0 1 PRESSURE ❑ 2.GRIT <br /> AVY 0 3_CONVENTIONAL SUCTION 13 4.SAFESUCDON In CCR#2636(.X3)) 45a. <br /> PRIMARY CONTAINMENT 0 I.STEEL ® 4.FIBERGLASS 0 S.FLEXIBLE <br /> 0 9o.NONE ❑ 95.UNKNOWN ❑ 10.RIGm PLASTIC 464 <br /> 0 99.OTH 'fy) 464 <br /> SECONDARY CONTAINMENT E3 1.1.STEEL ® 4.FIBERGLASS ❑ R.FLEXIBLE _ ❑ 10.RIGID PLASTIC 4446 <br /> 0 90.NONE ___ 0 95.UNKNOWN _ __0_99.GTHER(Spnty);_ +64r <br /> PIPfNG/TURBINE CONTAINMENT SUMP TYPE 0 I.SINGLE WALL ❑ ?.DOUBLE WALL ❑ 90.NONE - - 4646 <br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT 0 L STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Spc N) ae a <br /> VENT SECONDARY CONTAINMENT 0 L STEEL 0 4.FIBERGLASS 0 l0.RIGID PLASTIC 0 90.NONE 0 99.OTHER(S xxdy) 46"n <br /> VR PRIMARY CONTAINMENT 0 1.STEEL M 4.FIBERGLASS 0 10.RI01D PLASTIC 0 90.NONE 0 99.OTHER(specify) 4a4 <br /> VR SECONDARY CONTAINMENT 0 L STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC ® 9o.NONE 0 99.OTHER(Specify): 46x. <br /> VEIN PIPING TRANSITION SUMP TYPE0 1.SINGLE WALL 0 2.DOUBLE WALL 0 90.NONE 464Hi. <br /> RISER PRIMARY CONTAINMENT 0 I.STEEL ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 0 99,OTHER(Specify): <br /> +641. <br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE E399.OTHER(Specify): 461k1 4 k <br /> FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET 0 3.STRIKER PLATE/sw-tom PROTECTOR 0 4.CONTAINMENT SUMP 451e <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ® 1 SINGLE WALL ❑ 1.DOUBLE WALL 0 1 NO DISPENSERS 0 90.NONE 469a <br /> CONSTRUCTION MATERIAL ® I.STEEL 0 4.FIBERGLASS 010 RIGID PLASTIC 0 99.OTHER(Specify) 459c <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION 0 2.SACRIFICIAL ANODES) 0 J.IMPRESSED CURRENT 0 6.ISOLATION 44a <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, <br /> accurate.and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 4/28/2011 +70. <br /> APPLICANT NAME(print) Sandy EJwards 411. APPLICANTTITLE Environmental Compliance 4n. <br /> UPCF UST-B Rev.(11/2087)-1/2 www.unidocs-org <br />