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IED PROGRAM CONSOLIDATED FO* UNDERGROUND STORAGE TANK 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,11,111,IV,and IX below) 410 ❑ 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 I DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Ont)) - I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 Yosemite 76 BUSINESS SITE ADDRESS 103 r CITY 104 1700 East Yosemite Avenue I Manteca II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 2- Premium MODERN ® 1.A STAND-ALONE TANK ❑2.ONE IN A COMPARTMENTED UNIT. Complete one page for each compartment in the unit. DATE UST SYSTEM INSTA L D 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 1987 '.p 12,000 III.TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ® lb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL EI 9.OTHER PETROLEUM (Specify): 44oa NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL [311.OTHER NON-PETROLEUM(Specify): 44ob IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT F 1.STEEL ❑ 3.FIBERGLASS ❑ 6.nY TERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ® 7.JACKETED 445 ❑ 90.NONE Cl 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION ® I.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT N 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE-WALLED ®2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ® I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464e PIPING/TURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I.STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT Cl 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 46417 46417 VR PRIMARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90. ONE ❑ 99.OTHER(Specify) 464h C°p•"' 464h1 VENT PIPING TRANSITION SUMP TYPE ® I.SINGLE WALL ❑ 2 DOUBLE WALL ❑ 90.NONE ! '" 464', RISER PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90 NONE ❑ 99.OTHER(Specify) 'R- :a 4641 4641 RISER SECONDARY CONTAINMENT ❑ I.STEEL E 4.FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED ® L SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ® 4.CONTAINMENT SUMP "' i 45la-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ® L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 46967 VIII. CORROSION PROTECTION ; STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) [14.IMPRESSED CURRENT ® 6.ISOLATION 448. IX. APPLICANT SIGNATURE 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. 470 AP LIC NATURE DATI3.-'ri1{z�h�26� AP�?LICANNTNAME(print) 471 A PLICgjV TITLE 472, UPCF UST-B-1/2 Rev.(12/2007)