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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (one form per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11,111,IV,and GY 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 rda ;lhi u I� .t DATE UST PERMANENTLY CLOSED: 430a. I DATE EXISTING UST DISCOVERED: 13Vi ritJiV[U��P<i'i"L I. FACILITY INFORMATION FACILITY ID k(Agency Use Only) _ 1 BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. B &W PETROLEUM# 98 dba H&M MARKET BUSINESS SITE ADDRESS 103. CITY 104• 2501 JACKSON ST. ESCALON, CA. 95320 II. TANK DESCRIPTION TANK ID N 432, TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434, 39000213148 0507895 MODERN WELDING ❑ 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. UNKNOWN 6,000 2 III. TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ le.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ---- �- -0 6.OTHER GENERATOR FUEL �- [195.UNKNOWN- --- - ❑ 99.OTHER(Specify)_ 439s. CONTENTS PETROLEUM: ❑ 1a.REGULAR UNLEADED ❑ Ic.M1 GRADE UNLEADED ® Ib.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS _ ❑_8._PETROLEUM BLEND FUEL 0 9.OTHER PETROLEUM(SEecify): 4404. - NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 444'. IV. TANK CONSTRUCTION TYPE OF TANK_ _ ❑_I.SINGLE WALL ® 2.DOUBLE WALL ❑ 95._UNKNOWN __ 443 PRIMARY CONTAINMENT C1L STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER_ _ 0 7.STEEL+INTERNAL LINING _❑_ 95.UNKNOWN O 99.OTIIER(S�ecify 444x_ SECONDARY CONTAINMENT r[1 1.STEEL [13.FIBERGLASS _ ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. __ _ ❑ 90.NONE_ _ [195.UNKNOWN El99.OTHER(_Specify): 445x_ 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 CONSTRUCTION PIPING CONSTRUCTION11 .OTHER 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 99ER ... SYSTEM TYPE _- -® 1.PRESSURE0_2.GRAVITY _^ ❑ 3.CONVENTIONAL SUCTION _4.SAFE SUCTION[23 CCR§2636(a)(3)] �T PRIMARY CONTAINMENT 0 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. _ C3 90.NONE _❑ 95.UNKNOWN _❑ 99.OTHER(Specify): _4648___._ SECONDARY CONTAINMENT ❑ 1.STEEL-- ❑ 4.FIBERGLASS _ ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. PIPIUR ___ _ El 90.NONE ® 95.UNKNOWN _❑ 99.OTHER(Specify): 464c. NGlfBII4E CONTAINMENT SUMP TYPE ® 1.SINGLE WALL [12.DOUBLE WALL ❑ 90.NONE a54d.- VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ® 99.OTHER(Specify):UNKNOWN 46401. - 464f. VENT SECONDARY CONTAINMENT ❑ 1,STEEL ❑ 4,FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 1@ 99.OTHER(Specify):UNKNOWN 464fl. _. - _ ---- .,... 4648. VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ® 99.OTHER(Specify):UNKNOWN 46a$t: VR SECONDARY CONTAINMENT -❑ 1.STEEL ❑-4,FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ® 99.OTHER(Specify):UNKNOWN 4601. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 46at' 464), RISER PRIMARY CONTAINMENT ❑ I.s,rEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ® 99.OTHER(Specify):UNKNOWN 464)1.__ __.........________._--.------_____.__.__.___.----.____.........-------.---.-_..----.__---.-----._-----.----..___ _._- RISER SECONDARY CONTAINMENT El1.STEEL E] 4.FIBERGLASS [110.RIGID PLASTIC C190.NONE ® 99.OTHER(Specify):UNKNOWN 464L FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 431a-c VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE _----- ® 1.SINGLE WALL ❑ 2.DOUBLE WALL^� ❑ 3.NO DISPENSERS- 0 90.NONE 469a. 459b. CONSTRUCTION MATERIAL ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PRO'T'ECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 449. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that t T y em is compatible with t "Azardous substance stored and that the information provided herein is true, accurate,and u i e 'h e vire ents. APPLICANT SIGNATURE DATE 10/4/201 1 470 APPLICANT NAME(print) RO A HENRY 471• APPLICANT TITLE OUST. SERV. COO 472 UPCF UST-B Rev,(12/2007)-112 www.unidocs.org <,