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3 13dl 10 IED PROGRAM CONSOLIDATED FO 111 D UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) a3o ❑ 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) D /� 1 3 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) Shell & Mini Mart BUSINESS SITE ADDRESS l03 CITY 104 3725 N.Tracy Boulevard Trac II:TANK DESCRIPTION..; 434 TANK ID 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 1-R lar Owens Corning ®1.A STAND-ALONE TANK ❑2.ONE IN A COMPARTMENTED UNIT. p U x i, Complete one page for each compartment in the unit. DATE ST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 5-22-1990 12000 IIL TANK USE AND CONTENTS TANK USE E la.MOTOR VEHICLE FUELING ❑ Ib.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 F-195.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: ® la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ lb.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): aaob IV: TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL E 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL E 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ L STEEL E 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN [199,OTHER(Specify): 445a OVERFILL PREVENTION ® 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT E 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-WALLED E 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ® L PRESSURE Ll 2.GRAVITY [13.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(ax3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL E 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464° PIPING/TURBINE CONTAINMENT SUMP TYPE E 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d YI'vEIT,VAPOR RECOVERY.(V R)"ANDI SER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT Ll1.STEEL ® 4.FIBERGLASS ❑ ]0.RIGID PLASTIC Ll 90.NONE ❑ 99.OTHER(Specify) 464e IM 464e1 VENT SECONDARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 46411 VR PRIMARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464stl VR SECONDARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE E 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464'. RISER PRIMARY CONTAINMENT E L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 464j 1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL E 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 4641 FILL COMPONENTS INSTALLED E 1.SPILL BUCKET E 3.STRIKER PLATE/BOTTOM PROTECTOR E 4.CONTAINMENT SUMP 451 a-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE E 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ L STEEL E 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696-c Vin. CORROSION PROTECTION i STEEL COMPONENT PROTECTION [12.SACRIFICIAL ANODE(S) [14.IMPRESSED CURRENT E 6.ISOLATION a4s. IX. APPLICANT SIGNATURE CERTIFICA I certify that this UST sys a incompatible with the hazardous substance sto ed an. that the information provided herein is true,accurate, and in ull co liance withal re uirements. azo. LICA U ' DATE l APPrICA4 NAME(prin 471. APPLIC TIT/E 472. Aura Sibley for Shell Oil Prodfiefs,US HS&E C pliance Coordinator UPCF UST-B-1/4 Rev.(12/2007)