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FIED PROGRAM CONSOLIDATED FO i UNDERGROUND STORAGE TANK c1 OPERATING PERMIT APPLICATION-TANK INFORMATIO (One form per UST) TYPE OF ACT ION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11,111,IV,and IX below) c>( 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. I DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) - - C) a 1. BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3' Kaiser Permanente Medical Offices BUSINESS SITE ADDRESS 103. CITY 104. 7373 West Lane Stockton II. TANK DESCRIPTION TANK ID# t4C-' 432. TANK MANUFACTURER 433• TANK CONFIGURATION:THIS TANK IS 434. TA0249401(39000232484024 ( Owens Coming ® 1.A STAND-ALONE TANK Complete one page for each 9401 g ❑ 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. 1990 12,000 1 III. TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil ® 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERA .. ...................... . ..........................................................................................................................................................................._........................................................................................................................................ CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ 16.PREMIUM UNLEADED 440. ® 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440a. ........................................................................................................................................................................................................................................................._............._...................__...._..._............................................................... NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN �3' PRIMARY CONTAINMENT 111.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444a. . ........................................................................................................................ . ............................................................................................................................................................................................................... SECONDARY CONTAINMENT ❑ I.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445x. ............................................................................................. .................. .................................................. OVERFILL PREVENTION ❑ I.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT PL 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 WALL 2.DOUBLE WALL r_199.OTHER 460. . ........................-....................................._......................................................._............................................................................................................................................................................................................................................................................................................................................................................................................. SYSTEM TYPE ❑ I.PRESSURE ❑ 2.GRAVITY3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458. PRIMARY CONTAINMENT ❑ 1.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 46a . ❑ 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 RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION 464e. VENT PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): q64el ................................................................................-........................................................................................... ..............f..... VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 46411. ............................................................._.....................I........................._._........_...................................._...................................._............................................................................................................................................-......................_._............................_......_.................................................................... ............... VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS [:] ® 464g. 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 464gt,,_. ....._. __._.............................................................................................................................................................................................................................................._............... VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464hl. ..........................................._...................................__..............................................................................................................................................................................................................................................................................................................................................................-......................................... 64. VENT PIPING TRANSITION SUMP TYPE [:] 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE a ..................................................................................................................................................................._........................_..................................................................................................................................................4..4..... RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): g41. 64j ..............................................................................................................................._. ........................._............___..._................................................................................................................... .. ............... RISER SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify):. 464k1: . . .... ....................................................................._.........................................................................................................................................._....................... ....._............................._....._........................................................................................................................ FILL COMPONENTS INSTALLED ® I.SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR [14.CONTAINMENT SUMP 451a-c. VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ® 90.NONE 469a. ..................................................................................................................................................................................._................................. 469b. CONSTRUCTION MATERIAL ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) '^a, 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATI 448• X. APPLICANT SIGNATURE CERTIFICATION: I certify that US ste is c mpatible with the hazardous substance stored and that the inforfnation provided herein is true, accurate,an in f II c m 'an e i legal requirements. azo. APPLICANT SIGNATURE DATE 7/22/2011 F, UPCF UST-B Rev.(12/2007)-1/3 www.Unidoes.org