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IFIED PROGRAM CONSOLIDATED AW Lid�L17 ma"allila 01.1 01IRM0141 Inwil OPERATING PERMIT APPLICATION - TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal, complete only this section and Sections I, II, III, IV, and IX below) 430 X 1. NEW PERMIT ❑ 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a IDATE EXISTING UST DISCOVERED: 430b FACILITY ID # (Agency Use Only) I - I I I 1 BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) 3 Quik Stop #124 BUSINESS SITE ADDRESS 103 CITY 104 505 N. Main Street Manteca TANK ID # 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 3 Xerxes X 1. A STAND-ALONE TANK ❑ 2. ONE IN A COMPARTMENTED UNIT. Complete one page for each compartment in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 10,000 1 TANK USE x la. MOTOR VEHICLE FUELING ❑ lb. MARINA FUELING ❑ lc. AVIATION FUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 5. EMERGENCY GENERATOR FUEL [HSC 425281.5(c)] ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la. REGULAR UNLEADED ❑ lc. MIDGRADE UNLEADED X 1b. PREMIUM UNLEADED 440 ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (Specify): 440a NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ❑ 11. OTHER NON -PETROLEUM Specify): 440b TAIYK,C(?NSTRi3CTION . . TYPE OF TANK ❑ 1. SINGLE WALL x 2. DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT ❑ L STEEL X 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 ❑ 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1. STEEL X 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 445a OVERFILL PREVENTION ❑ 1. AUDIBLE & VISUAL ALARMS ❑ 2. BALL FLOAT x 3. FILL TUBE SHUT-OFF VALVE 452. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT ... R1i I CTCT } WASTE PIPiN C(}NST IVIG ON PIPING CONSTRUCTION ❑ 1. SINGLE -WALLED x 2. DOUBLE -WALLED ❑ 99. OTHER 460 SYSTEM TYPE x 1. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION (23 CCR §2636(x)(3)] 458 PRIMARY CONTAINMENT ❑ I. STEEL X 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL x 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464b ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE 4644 YI:, 15TT,VAP(IR RECOERX (Y ANI}.RIEI,1 FII PIP.PIPING CONTUCTION VENT PRIMARY CONTAINMENT ❑ 1. STEEL x 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1. STEEL x 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464f 464fl VR PRIMARY CONTAINMENT ❑ 1. STEEL X 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Soecifv) 464g VENT PIPING TRANSITION SUMP TYPE ❑ 1. SINGLE WALL x 2. DOUBLE WALL ❑ 90. NONE 4641. RISER PRIMARY CONTAINMENT x 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 4641 464' 1 RISER SECONDARY CONTAINMENT [711. STEEL x 4. FIBERGLASS ❑ 10. RIGID PLASTIC 177190. NONE ❑ 99. OTHER (Snecifvl 464k PILL U)MYUNI1N I S INS I ALLhU x 1.NVILLISUU&C.1 X.i.SlKl&hKFLAIt/tSUIlUMFKU1tUIUK X 4.UUNIA1NMhNTSUMF UNDER DISPENSER CON"TAI ENT (UDC) CONSTRUCTION TYPE X 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 469a CONSTRUCTION MATERIAL ❑ 1. STEEL x 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 469b -c yIII CORROSION PROTECTIC3N STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION 448, APFLICtNT.SIGNATt7RE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate, and in full compliance with legal requirements. APPLICANT SIGNATURE:�� DATE azo. APPLICANT NAME (print) Dulcinea Covan 471. APPLICANT TITLE Compliance Manager 471 UPCF UST -B - 1/1 Rev. (12/2007)