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UNIFIED PROGRAi1-1 CONSOLIDATED FORIM <br />UNDERGROUND STORAGE TANK <br />OPERATING PERMIT APPLICATION -TANK INFORMATION (Orae form per UST) <br />TYPE OF ACTION (Check are hent only. Fara UST closure or• rentotml, complete only this section and Sections 1,11,111.1►! mrd l.V belox,) 430. <br />❑ 1. NEW PERIMIT ® 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION <br />❑ 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ S. UST REiV(OVAL <br />DAVE UST PFRMANENTLY CLOSED: 4300 DATE EXISTING UST DISCOVERED: 430b <br />I. FACILITY INFORMATION <br />FACT LITY ID # (Agency Use 0s171 - 1 <br />BUSINESS NAME (Same as Facility Nome or DRA - Doing Bmsinoss As) 3. <br />Flyers #487 <br />BUSINESS SITE ADDRESS 103 <br />CITY „" <br />983 Moffat Blvd <br />Manteca <br />II. TANK DESCRIPTION <br />TANK ID # 432. <br />"I'ANK MANUFACTURER 433. <br />TANK CONFIGURATION: THIS TANK IS 434 <br />2 <br />Moderil Welding <br />❑ 1. A STAND-ALONE TANK Conpleteow page for each <br />N 2.ONEINA COlvfPARTMF.NTEDUNIT companrxntinaeunit- <br />DATE UST SYSTEM NSTALLED 435. <br />TANK CAPACITY IN GALLONS 436. <br />NUMBER OF COMPARTMENTS IN THE UNIT 437, <br />1995 <br />81000 <br />2 <br />III, TANK USE AND CONTENTS <br />TANK USE N la. 100TOR VEHICLE FUELING ❑ Ib. MARINA FUELING ❑ Ic. AVIATION FUELING 434. <br />❑ 3. CI1EA11CAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (locludes Used Oil) ❑ 5. EMERGENCY GENFRATOR FUEL IIISC §252SI.5(Ol <br />❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 4390 <br />CONTENTS PETROLEUM: N la. REGULAR UNLEADED ❑ Ic. MIDGRADE UNLEADED ❑ lb. PREMIUM UNI.EADFD 44U <br />❑ 3. DIESEL ❑ S. JET FUEL ❑ 6. AVIATION GAS <br />❑ 8. PETROLEUM BLEND FUEL Q 9. OTHER PETROLEUM (Specify): 440a <br />NON -PETROLEUM: ❑ 7. USED OIL ❑ 1o. ETHANOL <br />❑ 11. OTHER NON -PETROLEUM (S ecif : 4tw' <br />IV. TANK CONSTRUCTION <br />TYPE OF TANK ❑ 1. SINGLE WALL N 2. DOUBLE WALL ❑ 95. UNKNOWN 443. <br />PRIMARY CONTANNIF.NT ®1. STEEL ❑ 3. FIBERGLASS [36. INTERNAL BLADDER 444' <br />❑ 7. STEEL r INTERNAL LINING ❑ 95. UNKNOWN [199.OTHER (Specify): 444a <br />_ <br />SECONDARY CONTAINMENT ❑ 1. STFFL ® 3. FIBERGLASS C3 6. 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445. <br />❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 4453 <br />OVERF)L1_ PREVENTION ❑ 1. AUDIBLE & VISUAL ALARMS ❑ 2. BALL FLOAT ® 3. FILL TUBE SHUT-OFF VALVE 452. <br />❑ 4. TANK MEETS RF UIREIMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPNIENT <br />V. PRODUCT/ WASTE PIPING CONSTRUCTION <br />PIPING CONSTRUCTION ❑ 1. SINGLE WALL N 2. DOUBLE WALL ❑ 99. OTHER 4Go- <br />C <br />SYS'TEM TYPE N 1. PRESSURE❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION (CR §2636(a)(3)I 45s. <br />_ - <br />-❑ <br />S. FLEXIBLE ❑ 10. RIGID PLASTIC21 <br />063 <br />PRIMARY CONTAINMENT ❑ i_ STEEL N 4. FIBERGLASS <br />[190. NONE C195. UNKNOWN ❑ 99. OTHER (Specify): 4640 <br />ODARY COTAINNIENT [11. STEEI, N 4. FIBERGLASS ❑ S. FLEXIBLE 10. RIGID PLASTIC 463b <br />SECNi N <br />❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464c <br />_ <br />PIPINGrFURBINE CONTAINMENT SUMP TYPE ® i. SFNGLF WALL ❑ 2. DOUBLE WALL ❑ 90. NONE 467d <br />VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION <br />VENT PRIMARY CONTAINMENT [11. STEEL N 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE (1 99. OTHER (Specify): 464cl . <br />VENT SECONDARY CONTAINMENT (3I. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC N 90. NONE [199.OTHER (Specify): �f <br />'-- -- 464. <br />VR PRINIARY CONTAINMENT ❑ (. STEEI. N 4. FIBERGLASS ❑ 10. RIGID PLASTIC -❑ 90. NONE ❑ 99. OTHER (Specify): 464 1, <br />VR SECONDARY CONTAINMENT ❑ 1. STEF,I. ❑ 4. FIBERGLASS [110. RIGID PLASTIC N 90. NONE ❑ 99. OTHER (Specify): 4Whlt, <br />7. <br />VENT PIPING TRANSITION SUMP TYPE ❑ L SINGLE WAIL ❑ 2. DOUBLE WALL N 90. NONE <br />RISER PRIMARY CONTAINNIENT ❑ L STEEI, N 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99.OTHER (Specify): 46441 <br />4wr <br />RISER SECONDARY CONTAINMENT ❑ I. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ® 90. NONE ❑ 99, OTHER (Specify): 464Ai <br />FILL COh9PONFNTS !NSTALLED ® I. PLATE/BOTTOM BUCKET N 3. STRIKER PLATEOTTOM PROTECTOR ❑ 4. CONTAINMENT SUMP 45,a•c <br />VII. UNDER DISPENSER CONTAINMENT (UDC) <br />CONSTRUCTION TYPE N 1. SINGLE WALT, ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 469a <br />CONSTRUCTION MATERIAL ❑ I. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC N 99.OTIIER (Specify) Poly 469c. <br />VIII. CORROSION PROTECTION <br />STEEI-.COMPONENT PROTECTION ❑ 2. SACRIFICIALANODE(S) ❑ 4.1\IPRr.SSHDCURRENT ❑ 6. ISOLATION 448 <br />IX. APPLICANT SIGNATURE <br />CF,ItTIFICA'I'ION: I certify that this UST system is compatible with the hazardous substance stored and that (he Infor1110 1011 Provided herein is true, <br />accurate ul in full compliance with legal requirements. <br />APPLICANT S[GNA"TURF <br />DATE 470 <br />10/4/2011 <br />444 <br />471. <br />APPLICANT NAME {print} Amanda Appelt <br />47z <br />APPLICANT TITLE e ger <br />Enviro3mlent i1 Mans <br />UPCF UST' -H Re, (12/2007)- 1/2 33.ww.unidocs.org <br />