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IED PROGRAM CONSOLIDATED FO UNDERGROUND STORAGE TANK 'OPERATING PERMIT APPLICATION-TANK INFORMATION (rine form per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections I,11,Ill,IV,and M below) 430. ❑ 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. 1 DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INF©RMATION FACILITY ID#(Agency Use Only)' 10 , 0 -., 0 0 0 3 9 7 8 L; BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. Kaiser Permanente Medical Center BUSINESS SITE ADDRESS 103. CITY 104. 1777 W. Yosemite Ave. Manteca II TANK DESCRIPTION" TANK ID# 432. TANK MANUFACTURER a33. TANK CONFIGURATION:THIS TANK IS 434. oa 3a'701 Owens Corning ❑ 1.A STAND-ALONE TANK Complete one page for each ® 2.ONE IN A COMPARTMENTED UNIT compartment in the unit. DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. 611988 8,000 1 II- TAS USE ANll CONTENTS. TANK USE ❑ 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§25281.5(c)) ❑ 6:OTHER GENERATOR FUEL ❑ 95:UNKNOWN ❑ 99.OTHER(Specify).: 439a. ....................... ._................ .................................................................................................................._.__......._._..__......_._.............._.... CONTENTS PETROLEUM: [3 la.REGULAR UNLEADED E] lc.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440. ® 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440s. ...................................................................................................._._............................ -_..._-._....._.......__..........._...._....................0................................................._......._........................_...................i:...... .............................................. NON-PETROLEUM:❑-7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 9 _....._._........_.........._.._..........._......._...................._................... ............_..... 5.UNKNOWN 44.3 ...................._..................._................................................._...................................._.........................................................._.........._......................................................_...................................................... . ..... PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING _.._..._._.._...._.............._ 95,UNKNOWN .99:OTHER(Specify): 444e. ._............._............._._.......... SECONDARY CONTAINMENT ❑ L STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445.. _............_...._. . . .......__.._.. ....................................................._............_.............................................._...._.-.................._..__......._..-------- __...._.........._....._........_............................_ .....--._.......__...... OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ® 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V«;'PRODUCT.%WASTE PIPING CONSTRUC'I`Xf PIPING CONSTRUCTION ❑ 1 SINGLE WALL ® 2 DOUBLE WALL 0 99_OTHER a60. -....... _. .......................................... ........................................................... SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(.)(3)) - 45g .. ..... ............................... PRIMARY CONTAINMENT ® L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC abl. ❑.._90:NONE..............................._❑ 95:..UNKNOWN (Specify):...... 464a. ..........._................................. ...... ....................................4646...... SECONDARY CONTAINMENT ❑ ].STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify):. 464c. ... .................... .............._......_.... PIPING/TURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d. VI., VENT,VAPOR RECOYERY SVR)AND RISER 1 FILL PIPE PIPING C)NSTRUCTION VENT PRIMARY CONTAINMENT ® 1.STEEL [14.FIBERGLASS [110.RIGID PLASTIC [190.NONE [:199.OTHER(Specify): 464el. ....... ......_..................................._..............................................................................................................._..................................._.............._......._.........._._......................._........._.....................- 461f. VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE [399.OTHER(Specify): 464fl, ......................................._....._....__...._..............._............_............................................................._..................... VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER. . . . ... . . . . . . . (Specify)..................... 46ge!.:...... ......................................................................................................................---......._...___........__._...._................._.............................................................................................................................................................._.._.................---...._..........._. 464h. VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464h1.,._.,, ........................................................................................................._......_.____._............._........_..._..._.................................._........................_.....................................................-........................................................_...................................................._._................. ............ 4�` VENT PIPING TRANSITION SUMP TYPE [11.SINGLE WALL [12.DOUBLE WALL ® 90.NONE ................. ......_............_....__............................................................................................464:...... RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): _............_....................__................._..........................._............. ................................................................._....................................................................._.-........_....__._......................._._.........................._.._...................................................................................................._._..........-................. 464k. RISER SECONDARY CONTAINMENT [11.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [399.OTHER(Specify): 464k1. FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a-c 'SII. UNDER DI NSER CIl1TAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2 DOUBLE WALL ® 3.NO DISPENSERS ❑ 90.NONE 469a. ......... _..................................................................................._.... ..... .........__..... _.._............ .............._.. .._...._..._.....---.._...._........._....................................................................._........................_........._................._............._.........._--�-......................................... 4696. CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c. VIII."CORROSItN PROTECTION STEEL COMPONENT PROTECTION [12.SACRIFICIAL ANODES [34.IMPRESSED CURRENT ® 6.ISOLATION ass IX P '!L C, TT°tSIGrN AT R R CERTIFICATION: I certify that thi UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate,and i ll com liars wi al a uirements. 470. APPLICANT SIGNATURE DATE 8/3/2011 APPLICANT NAME(print) Samuel A .Corbin 411. APPLICANT TITLE Chief Engineer p rA72 w UPCF UST-111 Rev.(12/2007)-1/2 www.unidocs.org u