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'06/04/2009 00:27 9252920074 GDF_SOLUTIONS FAX PAGE 15X15 <br /> . IFIED PROGRAM CONSOLIDATED FOIM <br /> UNDERGROUND STORAGE TANK <br /> OPERA'T'ING PERMIT APPLICATION-TANK INFORMATION ( (One form per usTJ <br /> TYPE OF ACTION (Check one Item only. For a UST closure or removal,complete only this section and Sections I,II,III,Il,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 ❑ 9.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430& 1 DATE EXISTING UST DISCOVERED: 430b. <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) _ I. <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> Country Club 76 <br /> BUSINESS SITE ADDRESS 103 CITY 104. <br /> 2575 Country Club Blvd Stockton <br /> II. TANK DESCRIPTION <br /> TANK ID# 7xL3432 TANK MANUFACTURER 433• TANK CONFIGURATION:THIS TANK IS 434. <br /> 5 <br /> UL#FP44I153 N�odenra We�dallg I.A STAM>ALONE TANK complew apsadwam <br /> ® 2,ONE IN A COMPARTMENTED UNIT OMpMIMOM in the unk <br /> DATE UST SYSTEM INSTALLED 435• TANK CAPACITY IN GALLONS 436, NUNMER OF COMPARTMENTS IN THE UNIT 637, <br /> 4/27/06 7,000 , <br /> III. TANK USE AND CONTENTS <br /> TANK USE ® la.MOTOR VEHICLE FURLING ❑ 1 b.MARINA FUELING ❑ IC.AVIATION FUELING 439, <br /> E] 3.CHEMICAL PRODUCT STORAGF. ❑ 4.HAZARDOUSInc <br /> WASTE( udes Uud all C35.RKWROENCY GM4ERATOR FUEL IHsc§2s2s1.5(.)) <br /> ❑ 6.OTHER GENERATOR FUEL_ _ _❑ 95.UNKNOWN _ ❑ 99.OTHER(specify): 439& <br /> CONTENTS PETROLEUM: ❑ I&REGULAR uNLLADLD ❑ 1c.MIPGRADE UNLEh DED ❑ Ib.PREMIUM UNLEADED d40• <br /> ® 3.DIESFL ❑ 5,JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 6.PETROLEUM BLEND FUEL ❑ 9.OTMR PETROLEUM S 440,k <br /> NON-PETROLi11 �.US3 OIG 10.ETHANOL <br /> ❑ 11,OTHER NON-PETROLEUM(SpecifyY. 440b. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK _❑ 1.SINGLE WALL 10 ?.DOUBLE WALL _❑ 95.UNKNOWN 443. <br /> PRIMARY CONTAINMENT~! IBI 1.STEEL L33_FIBERGLASS ❑ 6,INTERNAL BLADDER 444. <br /> Q 7.STEEL+INTERNAL[,WING__ ❑ 95.UNKNOWN _❑ 99.OTHER(Spexify): 44d& <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED <br /> e4$. <br /> ❑ 90.NONE ❑ 95.UNKNOWN _ ❑99.OTHER(Specify): 449& <br /> OVERFILL PREVENTION ® 1.AUDIBLE&VISUAL ALARMS 0 2.BALL FLOAT _ _ ❑ 3.FILL TUBE SHUT-OFF VALVE ase. <br /> Q 4.TANK MEETS RFOUREMENTS FOR EXEMPTION FROM OVERFILL PREVEN'T'ION EQUIpMEYrr <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING_CONSTRUCTION ❑ 1.SINGLE WALL_N 2.DOUBLE WALL ❑ 99.OTHER _ 460. <br /> SYSTEM TYPE _ ® 1.PRESSURE ❑ 2.GRAVITY -0 3.CONVENTIONA_I.SUCTION ❑ 4.SAFE SUCTION P CCR-2Fi3q, A3_L 458. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ B.FLE)aRRLE ❑ 10.RIGID PLASTIC 4". <br /> ❑ ",NONE ❑ 95.UNKNOWN_ ❑ 99.OTHER(Specify): 4649. _ <br /> SECONDARY CONTAINMENT ❑ I.STEEL0 4,FIBERGLASS ❑ S.FLEMuuii ❑ 10.RIGID PLASTIC 4607 <br /> ❑ 90.NONE _ ❑ 95.UNKNOWN ❑ 99,OT�S 4640. <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ® 2.DOUBLE WAIL ❑ 90.NONE 4644. <br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT N 1,STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90,NONE ❑ 99.OTHER(Spcaii�r): 44"1 <br /> VENT SECONDARY CONTAINMENT ❑ i STEEL ® 4.FIBERGLASS [1 10,10,RIGID PLASTIC ❑ 90.NONE ® 99.01M(Spe ify): 4648; <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL E4 4.FIBERGLASS ❑ 10,RTOW PLASTIC ❑ 90.NONE ® 99.OTHER(Specify); I <br /> VR SECONDARY CONTAINMENT - ❑ 1,STEEL ® 4.FIBERGLASS Q 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 460. <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL 0 2.DOUBLE.WALL ❑_w NONE 40N• <br /> RISER PRIMARY CONTAINMENT - 19 1.STEEL ❑ 4.FIBERGLASS 0 10.R1G1D PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): ' <br /> - _ - <br /> I, <br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10,RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Spc6fy): 4462k <br /> FILL COMPONENTS INSTALLED fR3.SPILL BUCKET 3.STRIKER PLA'I'MOTTOM PROTECTOR 4.CONTAINMENT SUMP 451 <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ❑ I.SINGLE WALL _ M 2.DOUBLE WALILO 3,NO DISPENSERS ❑ go.NONE 469& <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL N 4,FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 46k.� <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACREFICIAL ANO S) ❑ 4."NESSED CURRENT ® 6.ISOLATION 4+>I <br /> LX APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST syste ' ce bte with the hazardous substance stored aad that the information provided herein is true, <br /> accorat a ' fou rn nce wit A requirements. <br /> APPLICANT SIGNATURE DATE 5/6/2009 t70 <br /> APPLICANT NAME(peri 0 Dave Hi11dS 471 APPLICANT TITLE Sales Manager 471 <br /> UPCF UST-B Rev.(12/2007)-112 www.unidoes.org <br />