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UNIFIED PROGRAM CONSOLIDATED FORIM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one iteul only. For a UST closure or removal, complele only this section and Sections L 11, 771, Ji ; and LV belott) 430. ❑ 1. NEW PERMIT ® 3. RENEWAL PERMIT ❑ S. CHANGE OF INFORMATION ❑ 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ S. UST REMOVAL 430b. DATE UST PERMANENTLY CLOSED: A30a DATE EXISTING UST DISCOVERED: I. FACILITY INFORMATION FACILITY ID # (Agency Use Onl)) - 1 BUSINESS NrAME /Sarre as Facility Name or• DBA -Doing Business As) 3 Flyers #487 BUSINESS SITZ: ADDRESS 103' CITY taa. 983 Moffat Blvd Manteca II. TANK DESCRIPTION TANK IDH 4T2- MANUFACTURER 433• TANK CONFIGURATION: THIS TANK IS 434. N 1. A STAND-ALONE TANK Complete one page for each 1 Modern Welding (1 2. ONE INA COMPART,A£ENTFD UNIT compartment in the unit. DATE USTSYSTEM INSTALLED 435. TANK CAPACITY IN GAI.I..ONS 436. NIJMBPR OF COIe•IPARTMENTS IN TME UNIT 437. 1998 12,000 1 III, TANK USE AND CONTENTS TANK USE N la. ,LIOTOR VEHICLE FUELING ❑ Ib. MARINA FUELING ❑ le. AVIATION FUELING ❑ 3. CHFMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (includes Used Oil) ❑ 5. EMERGENCY GENERATOR FUEL [IISC �,25281.5(c)] 439. ❑ 6.OTIIER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99.071`1113R (Specify): - _ 440.. CONTENTS PETROLEUM: ❑ Ia. REGULAR UNLEADED ❑ Ic. MIDGRADE UNLEADED ❑ lb. PREMIUM UNLEADED ❑ 6. AVIATION GAS 03. DIESEL El 5. JET FUEL 440a- E] S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): _. NON-PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL 4aab ❑ 11. OTHER NON-PETROLEUM (Specify): IV. TANK CONSTRUCTION 443. TYPE OF TANK ❑ 1. SINGLE WALL ® 2.DOUBLE WALL ❑ 95. UNKNOWN 444. PRIMARY CONTAINMENT ® 1. STEEL ❑ 3. FIBERGLASS ❑ G. INTERNAL BLADDER 444a ❑ 7. STEEL. + INTERNAL. LINING 95. UNKNOWN ❑ 99. OTHER (Specify): 445. SECONDARY CONTAINMENT ❑ 1. STEEL ® 3. FIBERGLASS [36. EXTERIOR MEMBRANE LINER [17. JACKETED 9OTHER (Specify): _445a. Q 90. NONE 17195. UNKNOWN El9. 452 OVERFILL PRF,VENT'ION ❑ I. AUDIBLE. & VISUAL. ALARMS ❑ 2. BAIL. FLOAT ® 3. FILL TUBE SHUT-OFF VALVE. Q 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION E UIP,\-IFNT V. PRODUCT / WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1. SINGLE WALL N 2. DOUBLE WALL ❑ 99. OTHER - _.. _ 460 ass. Sl'S'1'ERI TYPE N 1. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION 23f CCR §2f36(a)(3)I - - 464. PRIMARY CONTAINTAENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ S. FLEXIBLE ❑ 10. RIGID PLASTIC 46U ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464b SECONDARY CONTAINMENT [11. STEEL ® 4. FIBERGLASS ❑ 3. FLEXIBLE ❑ 10. RIGID PLASTIC 464c. ❑ 90. NONE ❑ 95. MOWN Q 99.OTHER (Specify): -._ U,\ 464d. PIPINGITURBINL' CONTAINMENT SUMP TYPE N L SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE VI. VENT, VAPOR RECOVERY (VR) AND RISER! FILL PIPE PIPING CONSTRUCTION 464e. VENT PRI1MARY CONTAINMENT ❑ 1. STEEL N 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 464cI,,_ 4&it VENT SECONDARY CONTAINMENT ❑ 1. STEEL [14. FIBERGLASS ❑ t0. RIGID PLASTIC N 9D. NONE ❑ 99.OTHER (Specify): 464n• a64g. _ VR PRIMARY CONTAINMENT ❑ I. SITE[. N 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 49.OTHER (Specify): 4gt. VR SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ t0. RIGID PLASTIC ® 90. NONE E]99.OTHER (Specify): _ _ 4464h, _i VENT PIPING TRANSITION SUMP TYPE ❑ 1. SINGLE WALL ❑ 2. DOUBLE WALT. ® 9D. NONE RISER PRIMARY CONTAINMENT ❑ 1. STEEL N 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): ._ L64jl 4641: RISER SECONDARY CON'iA1NMEN'C ❑ I. STF.Fi. ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ®90. NONI? ❑ 99. O'f13ER (Specify}: 464kt. -_... .. _._.-___._ .... ._......__ _....... _. _._ __-__ -.. FiiL CORIPONENTS INSTALI.ED ® 1. SPILL. BUCKET N 3. STRIKER PLATE tBO'ITOM PROTECTOR ❑ 4. CON'fAlNry1L•N7 SIJAtP 4.la-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CUNS'TRUCTION TYPE ® 1. SINGLE WALL El2. DOUBLE WALE, ❑ 3. NO DISPENSERS ❑ 9D. NONE _. 469b CONSTRUCTION MATF..RIAL ❑ L STEEL ❑ 4. FIBERGLASS ❑ I0. RIGID PLASTIC N 99.OTHER (Specify) Poly 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) El 4. IMPRESSED CURRENT ❑ 6. (SOLATION 445. IY. APPLICANT SIGNATURE CERTIFICATION: I certify that tills UST system is compatible with the hazardous substance stored anti that the information provided hereilt is trite, necurat < 6 dill 11111 colli 1111lic it I a1 ret 0lreraents. 470 APPLICANT SIGNAT UI DATE 10/4/1] 471• APPLICANT NA��tE (print) Amanda A}�pelt APPLICANT TITLE Environmental Manager 47z. UPCF IIST-13 Rev. (12/2007)- 1/2 wwwamldocs.org