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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) <br /> TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,Il,III,IV,and IX below) 430 <br /> ® I.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: Ji " I DATE EXISTING UST DISCOVERED: 4306 <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Onfl9 I <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) <br /> ARCO 06080 <br /> BUSINESS SITE ADDRESS 103 CITY 104 <br /> 85 E. LOUISE AVENUE LATHROP <br /> II.TANK DESCRIPTION <br /> TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 <br /> 3 T^ f CONTAINMENT ❑I.A STAND-ALONE TANK <br /> I H SOLUTIONS ®2.ONE IN A COMPARTMENTED UNIT <br /> DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 417 <br /> 12,000 2 <br /> III.TANK USE AND CONTENTS <br /> TANK USE Z Ia.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Ic.AVIATION FUELING 439 <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] <br /> ❑ <br /> 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a <br /> CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED Z Ib.PREMIUM UNLEADED 440 <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ <br /> 11.OTHER NON-PETROLEUM(Specify): 4406 <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL Z 2.DOUBLE WALL ❑ 95.UNKNOWN 443 <br /> PRIMARY CONTAINMENT ❑ I.STEEL Z 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL Z 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a <br /> OVERFILL PREVENTION Z 1.AUDIBLE&VISUAL ALARMS Z 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 CONSTRUCTION ❑ I.SINGLE-WALLED ®2.DOUBLE-WALLED ❑99.OTHER 460 <br /> SYSTEM TYPE Z I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR§2636(a)(3)] 458 <br /> PRIMARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ &FLEXIBLE ❑ 10.RIGID PLASTIC 464 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a <br /> SECONDARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ &FLEXIBLE ❑ 10.RIGID PLASTIC 4646 <br /> ❑ 90.NONE ❑ 95,UNKNOWN ❑ 99.OTHER(Specify): 464c <br /> PIPINGfTURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL. ® 2.DOUBLE WALL ❑ 90.NONE 464d <br /> VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ I.STEEL Z 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90 NONE ❑ 99.OTHER(Specify) 464. <br /> 464el <br /> VENT SECONDARY CONTAINMENT ❑ I.STEEL Z 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f <br /> 464171 <br /> VR PRIMARY CONTAINMENT ❑ I.STEEL Z 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 <br /> 464 I <br /> VR SECONDARY CONTAINMENT ❑ I.STEEL Z 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h <br /> 464h1 <br /> VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL ® 2.DOUBLE WALL ❑ 90.NONE 464i. <br /> RISER PRIMARY CONTAINMENT ® I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 <br /> 4641 <br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL Z 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k <br /> 464k1 <br /> FILL COMPONENTS INSTALLED Z 1.SPILL BUCKET Z 3.STRIKER PLATE/BOTTOM PROTECTOR Z 4.CONTAINMENT SUMP 451a-c <br /> VII.UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ❑ 1.SINGLE WALT. Z 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a <br /> CONSTRUCTION MATERIAL ❑ I.STEEL Z 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 46%, <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.INIPRESSED CURRENT ❑ 6.ISOLATION 448 <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: 1 certify that this LIST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, <br /> and in full compliance wi <br /> jb legal requirements. <br /> APPLICANT SIGNATURE DATE 470. <br /> APPLICANT NAME(print) 47I. APPLICANT TITLE 472 <br /> RICHARD GOSSETT ENVIRONMENTAL COMPLIANCE SP CIALIST <br /> Arco 06080,Belshire Environmental Services <br />