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IED PROGRAM CONSOLIDATED FO IJ 1 -313d// `14f UNDERGROUND STORAGE TANK I wvJ OPERATING PERMIT APPLICATION-TANK INFO ON(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 El5.CHANGE OF INFORMATION 1� 1 D ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE [16 8.UST REMOVAL l DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORmATI{ FACILITY ID#(Agency Use Only) _ 3 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 Shell & Mini Mart BUSINESS SITE ADDRESS 103 CITY 104 3725 N... Boulevard Trac ' II.TANKDESCRIPTION'`. rx • - 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 el Owens Coming ® 1.A STAND-ALONE TANK Jr �� ❑2.ONE IN A COMPARTMENTED UNIT. Complete one page for each compartment in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 5-22-1990 12000 I TAWWUSE-AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING [Ilb.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] [16.OTHER GENERATOR FUEL [195.UNKNOWN El 99.OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la. 'GU ADED ❑ lc.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 ❑ 5.JET FUEL ❑ 6.AVIATION GAS END 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 443 PRIMARY CONTAINMENT ❑ L STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION ® 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT N 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. .PRODUCT/WASTE;PIPTNG CONSTRUCTION' PIPING CONSTRUCTION ❑1.SINGLE-WALLED ®2.DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(ax3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL ® 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 4646 ❑ 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 REC000�,(VR)'AND.RISER/FILL PIPE PIPING CONSTRICTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE El99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 4641 VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4646 4640 VR SECONDARY CONTAINMENT ❑ 1.STEEL ISI 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464i. RISER PRIMARY CONTAINMENT ® L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464] 464j] RISER SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 4641 FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATEBOTTOM PROTECTOR ® 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696-c VIII..CORROSION PROTECTION STEEL COMI'ONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ® 6.ISOLATION 448' IX. APPLICANT SIGNATURE CERTIFICAT certify that this UST sys em i compatible with the hazardous substance store and t t the information provided herein is true,accurate, nd in full com li ce wi le I requirements. azo. P ICAN S /�/ TE AP AME(print) (/ 471. APPI �Z��d TIT L 472. Aura Sibley for Shell Oil Products S HS&E Compliance Coordinator UPCF UST-B-3/4 Rev.(12/2007)