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Loi z <br /> S.tio0� <br /> UNIFIED PROGRAIN't CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) <br /> ITYPEOFACTION (Check one ileur onl)% Fol-a UST closure or removal,contplele only this section and Secfiorrs 1,11,III,Il!and IX helou) 430. <br /> ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ® 5.CHANGE OF INFORMATION <br /> ❑ 6.TE,'fPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE: ❑ 8.UST REMOVAL, <br /> DATE UST PERMANENTLY CLOSED: 4303 1 DATE.EXISTING UST DISCOVERED: 430b <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use O)rlj) <br /> BUSINESS NAM E(Saute as!•'ncilit),Mame or DBA--Doing Business As) 3 <br /> FLYERS #427 <br /> BUSINESS SITE ADDRESS to3. CITY 10x <br /> 3300 Waterloo Rd. Stockton <br /> II. TANK DESCRIPTION <br /> TANK ID# ()SO -1 i 432 'LANK MANUFACTURER 433- TANK CONFIGURATION:THIS TANK IS 434. <br /> ® 1.A STAND-ALONE TANK ConV'elc une page for each <br /> 42704 TruscO ❑ 2.ONF.INA CONIPARTNiF.NTEDUNIT eon4mrtnwnta,theunh <br /> DATE UST SYSTEM INSTALLED 435- TANK CAPACITY IN GALLONS x36. NUMBER OF COMPARTMENTS IN THE UNIT 437 <br /> UnknoWll f�'Zu•a3 10,000 1 <br /> TIL TANK USE AND CONTENTS <br /> TANK USE N la.N40'fOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc.AVIATION FUELING 430 <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE([ncladcs Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§252815(c)] <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a. <br /> CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ic.MIDGRADE UNI.F.ADED C) Ib.PREMIUM UNLEADED 440. <br /> N 3.DIESEL. ❑ 5.JET FUEL ❑6.AVIATION GAS <br /> ❑ 3.PETROLEUM BLEND FUEL N 9.OTHER PFTROLEUM(S�ecify): Red diesel 440a <br /> NON-PETROLEUNI:IT 7.­USED ❑ 10.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEU11i(Specify): aa06. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑_I.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN ------ __ 443 <br /> PRINIARY CONTAINMENT ® 1.STEEL - ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER a44 <br /> ❑ 7.STEEL 4-INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify 444a- <br /> 445 <br /> SECONDARY CONTAINMENT ❑ I.STEEL [13.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER N 7.JACKETED <br /> ❑ 90.,NONE ❑ 95.UNKNOWN p 99,OTHER(Specify): a35� <br /> UWPREVENTION ❑ 1.AUDIBLE&VISUAL ALARNIS El2.BALL FLOAT N 3.FILL TUBE SHUT-OFF VALVE 452. <br /> VE <br /> ❑ 4.TANK MEETS RE UIRFN4FNTS FOR EXFb(PTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION Q I_SINGLE WALL_ N 2.DOUBLE WALL ❑ 99.OTIIER 460. <br /> Sl'5TE11'1'l l'PE ® I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTSON(23 CCR§2636(a)(3)] 458. <br /> PRI,•1ARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ S.FLEXIBLE, ❑ 10.RIGID PLASTIC 464. <br /> ❑ 90.NONE [195.UNKNOWN El99.OTHER(Specify): a6aa <br /> SECONDARY CONTAINMENT ❑ I.STEEL. N 4.FIBERGLASS [1S.FLEXIBLE ❑ 10.RIGID PLASTIC a6ah <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 461c. <br /> 111PING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d <br /> VI, VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT [1 L STEF,I. ® 4.FIBERGLASS [310.RIGID PLASTIC Cl90.NONE ❑ 99.OTHER(Spccify): 464c, <br /> VENT SECONDARY CONTAINMENT (31.STEEL El 4.FIBERGLASS Cl 10.RIGIDPLASTIC N 90.NONF. [I99.OTHER(Specify): a�,fl: <br /> VR PRIMARY CONTAINNIENT ❑ L STEEL ® 4.FIBERGLASS [110.RIGID PLASTIC Q 9D.NONE Q 99.0THF.R(Specify): aea�, <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC N 9D.NONF. ❑ 99.OTHER(Specify): 464h1. <br /> -VENT PIPING TRANSITION SUMP TYPE Q 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE' 4", <br /> RISER PRIMARY CONTAINMENT (0 L STEFL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [I99.OTHER(Specify): a��j. <br /> a64t.' <br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC N 9D.NONE Cl 99.OTHER(Specify): 464k1 <br /> FILL C6i1•L06NENTS INSTALLFD N 1.SPILL BUCKET N 3.STRIKER PLATOBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUN4P a31a-c. <br /> VII. UNDER DISPENSER CONTAINMENT (UDC) <br /> CO_NSTRUC HON TYPE ® 1.SINGLE_WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a <br /> CONSTRUCTION MATERIAL ® I.STEEL 114.FIBERGLASS ❑ 10.RIGID PLASTIC [I99.OTHER(Specify) 469": <br /> VIII. CORROSION PROTECTION <br /> STEEL COM PONENT PROTECTION ❑ 2.SACRIFICIAL ANODES) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448 <br /> IX. APPLICANT SIGNATURE r. <br /> CERTIFICATION: I certify that this UST system Is compatible with the hazardous substance stored and that the Inforiputlof►p•ovided herein is true, <br /> accurate,aiyLtn full c0n1 Bance Will'1 al re ulrelneuts. <br /> .•� azo <br /> APPLICANT SIGNATURE DATE 5/18/2012 <br /> APPLICANT NAME(print) Amanda Appelt x71APPLICANTTITLE EnvirOlental~ anagen a7z. <br /> UPCF UST-B liev.(112/2007)-1/2 mviv,unldocs.org `'r <br />