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06/04/2009 00:27 9252920074 GDF_SOLUTIONS FAX PAGE 13115
<br /> UNIFIED PROGRAM CONSOLIDATED FORM E,
<br /> UNDERGROUND STORAGE TANK
<br /> OPERATING PERMIT' APPLICATION-TANK INFORMATION (On-
<br /> TYPE OF ACTION (Check one item only. ,For a UST closure ar 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. 1 DATE EXISTING UST DISCOVERED: 430b.
<br /> I. FACILITY INFORMATION
<br /> FACILITY ID#(Agency Use Only) - 1.
<br /> BUSINESS NAME(Same as Facility Name or DBA-,Doing Business As) 3.
<br /> County ClUb 76
<br /> BUSINESS SITE.ADDRESS 143T CITY IQ0
<br /> 2575-Country Club Blvd I Stockton
<br /> II. TANK DESCRIPTION
<br /> TANK ID# r (�j j s' ? °3z. TANK MANUFACTURER 433• TAMC CONFIGURATION:THIS TANK IS 434.
<br /> UL#P441153 3 Modern Welding ❑ 1.A STAND-ALONE TANK C*M®j«e ane PAee fa MO
<br /> ® 2.ONE IN A CONeARTNIENTED UNIT -par-am in the unit.
<br /> DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLCiNS 436, NUMBER OF COMPARTMENTS IN THE UNIT 437.
<br /> 4/27/06 8,000
<br /> III. TANK USE AND CONTENT'S
<br /> TANK USE 19 la.MOTOR VEHICLE FUELING ❑ 1b.MA.R[NA FUELING ❑ lo.AVIATION FUELING d39•
<br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(1xiewdes Use4 Oci) ❑ S.SMIMOENCY GENERATOR FUEL CHSC§15281.5(03
<br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95,UNKNOWN El99.OTHER(Specify): 439&
<br /> ..______....__.__.___._._..-.--.-_•-_----....-..
<br /> CONTENTS PETROLEUM: ❑ Int.REGULARUNLEADED ❑ lc.N[IDGRADE UNLEADED 19 ib.PREMIUM UNLEADED
<br /> ❑ 3.DIESEL ❑ 5,JET FUEL [16.AVIATJON GAS
<br /> ❑ 8,PETROT.EUM ELEND FUEL ❑ 9.OTHER PETROLEUM(9&ecif�y. °AQj"
<br /> .NON-PETROLEUM,�7,USI D OIL -� U 10.ETHANOL Y w���
<br /> CI 11.OTHER NON-PETROLEUM S eciif : 44M,
<br /> IV. TANK CONSTRUCTION
<br /> TYPE OF TANK_ --___El 1,SINGLE WALL. (A,2•,DOUB�E.WAIII...--Q..-vs^[mK.r N ...._._..._
<br /> 443.
<br /> PRIMAItX CONTAIN 0 1.STEEL 133.FIBERGLASS ❑ 6.INTERNAL BLADDER------ W.
<br /> ❑ 7.STEEL+INTERNAL_L LINING 1395.UNKNOWN 1199.OTHER(Spccify): _4444
<br /> SECONDARY CONTAINMENT ❑ 1.STEEL- ®3.ME,RGLASS _ [36.EXTERIOR MEMBRANE LINER---❑ 7.JACKETED 4 aas.
<br /> ❑ 90.NONE _ _❑ 95,UNKNOWN 1199.OR(Spcci£y aa5o
<br /> OVERFILL PREVENTION � x AUDIBLE&VISUAL ALARMS .BA1I L FLOAT ® 3.FI4I IUBE SIIUT OFF VAI V6 aSz
<br /> p.TANK rIEETS RE UIRENSNTS FOR EXENUnION FROM OVERFILL PREVENTION T U NT
<br /> V. PRODUCT /WASTE PIPING CONSTRUCTION
<br /> PIPING CONSTRUCTION - ❑ 1._SINGLE WALT,_® 2.DOUBLE WALL 0 99.OTKR _ _ - � � ........... _ 460•
<br /> SYSTEM TYPE 1.PRESS'URIE El 2.GRAVITY- ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION_(23 ccR gz635Lax3)j 451,
<br /> PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.F113ERGLASS ❑ s.Fl mcrsLE ❑ 10.RIGH PLASTIC 464•
<br /> ❑ 90,NONE _❑ 95.UNKNOWN ❑ 99.OTHER(Specify): -- �464&
<br /> SECONDARY CONTAINMENT ❑ I.STEEL W 4.FIBERGLASS ❑ 6,FLExiBLE ❑ 10.RIGID PLASTIC 464x°.
<br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑-2;. (Specify): 464c. ry
<br /> PIPTNG/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ® 2,DOUBLE WALL ❑ 90,NONE
<br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION
<br /> 'TENT PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FISEItGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): �4464e.
<br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL [f 4.FIBERGLASS ❑ 10.RIGID PLASTIC 1190_NONE ❑ 99.0'1MR(SpeOY): MAfl.
<br /> _...__._...__-___.___..__�...�..-.....,.,,....•.,.,..,.P�.-�.-.-- 4648.-
<br /> VR PRIMARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90.NONE ❑ 99,OTI(ER(Specify): 446&
<br /> .......,. ..___...__..,.w..,.__ .m ,.,..,.-, _
<br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL ® a,FIEERGLASS ❑ 10.RIGID PLASTIC ❑ ",NONE ❑ 99.OTHER(Spec*):
<br /> 424W'
<br /> VR
<br /> PIPING TRANSITION_SUMP TYPE _ ❑ 1.SINGLI7_WALL ® 2.130UBT.E WALL. ❑ 90:NON>3 '-
<br /> RISER_PRIMARY CONTAINMENT_ ® 1.STEEL ❑ 4,FIBERGLASS_ -010.RIGID PLASTIC ❑_90,NONE ❑ 99.0'1fMP(Specify): e�
<br /> RISER SECONDARY CO_N_TAINMENT ❑ 1.STEL ® 4.FIB GLASS _❑ 10.RIGID PLASTIC _❑ 90.NONE ❑ 99.OTHER(Specify):
<br /> FILL COMPONENTS-INSTALLED- JLL SPILL BUCKET JK3.STRIKER PLATEIBOTTOM PROTECTOR 4.CONTAINMENT SUMP
<br /> I. UNDER DISPENSER,CONTAINMENT (UAC)
<br /> CONSTRUCTION TYPE___._._..._.___.._...._.- 1.SINGLE WALL-- ® 2.DOUBLE WALL _❑ 3.N0 DISPENSERS_❑ 90.NONE
<br /> CONSTRUCTION MATERIAL ❑ 1,S'x t ® 4,FIBERGLASS ❑ 10,RIGID PLASTIC ❑ 99.On-MR(Specify)
<br /> VIII. CORROSION PROTECTION
<br /> STEEL COMPONENT MOTECTION ❑ 2.SACRIFICIAL ANOTAI S) ❑ a.a wAsSED CU1LuNT ® 6.150LATION 449.
<br /> IX. APPLICANT SIGNATURE
<br /> CERTIFICATION: I certify that this UST s is c atible.with the hazardous substance stored and that the information Provided herein is true,
<br /> accurate I lie PlUjance w- legal requirements.
<br /> APPLICANT SIGNATURE DATE 5/6/2009 470,
<br /> APPLICANT NAME(print) Dave Hinds APPLICANT TITLE Sales Manager an.
<br /> UPCF UST-B Rev.(12J2007)-1/2 www.auidocs.org
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