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06/04/2009 00:27 9252920074 GDF_SOLUTIONS FAY, PAGE 14/15
<br /> 1%11A-
<br /> "UNIFIED PROGRAM CONSOLIDATED FOR J 6�
<br /> UNDERGROUND STORAGE TANK
<br /> OPERATING PERMIT At,PPLICATION-TANK INFORMATION (one form per UST)
<br /> TYPE OF ACTION (Check one item only. For a U'S'T closure or removal,complete only this section and Sections 1,11.111,IV,and abelow) 430.
<br /> ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION
<br /> © 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ S.UST REMOVAL
<br /> DATE UST PERMANENTLY CLOSED: 430- 1 DATE EXISTING UST DISCOVERED: 430b.
<br /> I. FACILITY INFORMATION
<br /> FACILITY ID#(Agency Use Only)
<br /> BUSINESS NAME(Same as Facility Name or DBA-Aoi>;g Business As) 3.
<br /> Country Club 76
<br /> DUSINESS SITE ADDRESS 103. CITY 104,
<br /> 2575 Country Club Blvd Stockton
<br /> II. TANK DESCRIPTION
<br /> TANK ID# 4'Z TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434•
<br /> / l J 0 1.A STAND-ALONE TANK Com fete onefbT
<br /> ULNP441152 Modern Welding p nth unit,
<br /> ❑ 2.ONE IN A COMPARTMENTED UNIT compartment in the unit,
<br /> DATE LIST SYSTEM INSTALLED aas. 'LANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN TIDE UNIT 437,
<br /> 4/27/06 15,000 1
<br /> M. TANK.USE AND CONTENTS
<br /> TANK USE ® Ia,MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ 1c.AVIATION FUELING 439•
<br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.ENIFRGENCY GENERATOR FUEL[RSC§252sl.s(o)]
<br /> ❑ 6.OTHER GENERATOR FUEL ❑ 9$,UNKNOWN_ _ _ ❑ 99,OTkT (SEecifsy�, aa9a
<br /> -CONTENTS PE'T'ROLEUM: 9 la REGULAR UNLEADED � r ❑ 1t'MMGRADE UNLEADED--- ❑ Ib.PUKUM UNLEADED a4Q•
<br /> ❑ 3.DIESEL. ❑ 5.JET FUEL ❑ 6.AVIATION GAS
<br /> -- __ _ 13S.PETOLEUM BLEND FUEL D 9.OTKER PETROLEUM S Ify)_- 440x.
<br /> NOFI-PIzIItOI 6UM.0 TU-N--'50-IL M�_Y---- 10.ETI{AF]OL ---
<br /> ❑ 11.OTHER NON-PETROLEUM S eci : 440b.
<br /> IV. TANK CONSTRUCTION
<br /> TYPE OF TAMC ❑ 1.SINGLE WAL _._L ®-2.DOUBLE WALL ❑ 95.UNKNOWN-....„,...W..y._-.........-._-------.- 443•
<br /> ,,,,,,,,„,. .._...._._._.__.___..._._,„�.•- ^^�-^ -- -
<br /> PRIMARY CONTAINMENT IN 1.STEEL ❑ 3.FIBERGLASS El6,INTERNAL BLADDER 444.
<br /> ❑ 7.STEEL+INTERNAL LINING --_❑ 95.UNKNOWN _0 99.OTIMR(Sp-ify): 4g4a
<br /> SECONDARY CONTAINMENT ❑ 1.STEEL__r ...®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7,JACKETED 445•
<br /> _LL 90.NONE ❑ 9S.UNKNOWN 1399.OTHER(Specify): 445a,
<br /> OVERFIPREVENTION- 1.AUDIBLE&VISUAL ALARMS ;Z.BALL FLOAT �� I� 3,FILL TUBE SHUT-OFF VALVE -
<br /> CI 4.TANK MEETS RE UIRENJENTS FOR EXEMPTION FROM OVERFILL PREVENTION E UHWENT
<br /> V. PRODUCT/WASTE PIPING CONSTRUCTION
<br /> PIPING CONSTRUCTION ❑ 1.SINGLE WALL 0 2.DOUBLE WALL._._.,D 99,OTHER .� 460.
<br /> -SYSTEM TYPE 1.PRESSURE O 2 GRAVI-TY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTIONz3SSU26j& 3 458.
<br /> PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FII3L•RGLASS ❑ 8.FLEXIBLE ❑ Lo.RLGTD PLASTIC 464•
<br /> -0.._90,_NONE - - 0 95.UNKNOWN ❑ 99.OTHER(Specify): 464a.
<br /> SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 46db.
<br /> ❑ 90.NONE• D 95.UNKNOWN ❑ 99.OTHER(SpssLfy): 464a
<br /> ____._...
<br /> PIPING/TURSINE CONTAINMENT SUMP TYPE ❑ I.SINGLE WALL ® 2.DOUBLE WALL. ❑ 90.NONE 464d,
<br /> VI. VENT,VAPOR RECOVERY (VR)AND RISER./FILL PIPE PIPING CONSTRUCTION
<br /> 4 .
<br /> VENT PRIMARY CONTAINMENT ® I.STEEL ❑ 4.FIBERGLwSS C110.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTLTI:R(Specify): g4�ele1
<br /> VENT SECONDARY CONTAINMENT- ❑-I STEEL ®4,FIBERGLASS El10.RIGID PLASTIC El 90.NONE 0 99.OTHER(Speeif),)� qbq
<br /> -._-_--------� -T 4.
<br /> VR PRIMARY CONTAINMENT ❑ I.STEEL ® 4.F113ERGLASS„ -D 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): q 19.
<br /> -
<br /> 43C.
<br /> VR SECONDARY CONTAINMENT _ ❑ I,STEEL ® 4.FIBERGLASS [I 10.RIGID PLASTIC ❑ 90.NONE ❑ 99,OTHER(Specify): ab
<br /> VENT PIPING TRANSITION SUMP TYPE --- El 1.SINGLE WALL ® 2.DOUBT.Ts WALL -❑ 90.NONE 2
<br /> RISER PRIMARY CONTAINMENT ® 1,STEEL D 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99,OTHER(Specify): 4464j.
<br /> _RISER SECONDARY CONTAINMENT ❑ ),STEEL R 4.FIBERGLASS El I0.RIGID PLASTIC_❑ 90.NONE D 99.OTHER(Specify): 484�
<br /> FILL COMPONENTS INSTALLED I.SPILL BUCKET _ 3.STRIKER PLATE/BOTTOM PROTECTOR JW4.CONTAINMENT SUMP 451a.c,
<br /> VII. UNDER DISPENSER CONTAINMENT OC)
<br /> CONSTRUCTION TYPE ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469k
<br /> -_ - ._._ �....._... _ _ ..... _ ,. -.---__
<br /> CONSTRUCTION MATERIAL 0 1.STEEL N 4.FIBERGLASS ❑ 10,RIGID PLASTIC 1399.OTHER(Specify) 400
<br /> VIII. CORROSION PROTECTION
<br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES D 4.IMPRESSED CURRENT IN 6,ISOLATION 448•
<br /> PLICANT SIGNATURE
<br /> CERTIFICATION: I certify qat4kik US stem is co ble with the hazardous substance stored and that the information provided herein IR true,
<br /> accurat ,and in om liauce al to uirementa
<br /> APPLICANT SIGNATURE DATE 5/6/2009 d70
<br /> APPLICANT NAIv(E(print)' Dave HhadS r7t. APPLICANT TITLE Sales Manager 472,
<br /> UPCF UST-B Rev.(12/2007) 112 wwwolaaifdoes-org
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