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0 • 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 LYfielou) 430. ❑ I.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) 1 BUSINESS NAME(Same as Facility Narne or DBA-Doing Business As) 3. B & W PETROLEUM # 98 dba H&M MARKET BUSINESS SITE ADDRESS 103. 1 CITY 104, 2501 JACKSON ST, ESCALON, CA, 95320 II. TANK DESCRIPTION TANK ID# 472• TANK MANUFACTURER 433• TANK CONFIGURATION:THIS TANK IS 434. 39000213148 0507 96 MODERN WELDING ❑ L 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 ❑ lb.MARINA FUELING ❑ Ic,AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL(HSC§25281.5(c)l __ ❑_6.OTIIER GENE_RAT_OR FUEL _ _❑ 95.UNKNOWN_ _ _ C199.OTHER(Specify): 439a. CONTENTS PETROLEUM: ❑ la_REGULAR UNLEADED- ❑ ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440. ® 3.DIESEL ❑ 5.JET FUEL ❑ 6,AVIATION GAS -- _ El 8,PETROLEUM BLEND FUEL [19.OTHER PETROLEUM(Speci p 440a. A^ NON-PETROLEUM: 7,USED OIL El10.ETHANOL �- ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV, TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 0 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL 0 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 ❑ 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4,TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION _❑_I.SINGLE WALL_® 2.DOUBLE WALL ❑ 99.OTHER 460. SYSTEM TYPE ® 1,PRESSURE _ ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR&2636(a_)(_3)J 45e.� PRIMARY CONTAINMENT ❑ 1.S'T'EEL - ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC^ - --} 464^ _ _ _ _ ___ ❑ 90.NONE _ _❑ 95.UNKNOWN _❑ 99.OTHER(Specify): 464x. SECONDARY-15 -0- & CONTAINMENT [31.STEEL _ [14.FIBERGLASS [18_FLEXIBLE - ❑ 10.RIGID PLASTIC 464h. __ _ __ _❑ 90.NONE _ ® 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. PIPrNGlrURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90,NONE _ - -464d. VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION 464 VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4•FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ® 99.OTHER(Specify):UNKNOWN 464e1. VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS [110.RIGID PLASTIC [j90.NONE ® 99.OTHER(Specify):UNKNOWN 464n, ._.. 48. VR PRIMARY CONTAINMENT [IL STEEL [:14.FIBERGLASS ❑ 10•RIGID PLASTIC ❑ 90.NONE ® .' UNKNOWN 46na199.OTHER(Specify): (6gl ... _... :.... ._ _.- --___._ „_._.____-___..._,__.._._.._.._-„_'.---._--....._--'""----------__-_._ 4641 VR SECONDARY CONTAINMENT [1I.STEEL [14.FIBERGLASS ❑ 10,RIGID PLASTIC ❑ 90.NONE ® 99.OTHER(Specify):UNKNOWN 464h,. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4641. -ifs-ii-PRIMARY CONTAINMENT [11.STEEL [14.FIBERGLASS [110.RIGID PLASTIC [190.NONE ® 99.OTHER(Specify):UNKNOWN 4644]1.- RISER SECONDARY CONTAINMENT-m❑ 1.STEEL -❑ 4.FIBERGLASS-❑ 10.RIGID PLASTIC [190.NONE ® 99.OTHER(Specify)UNKNOWN 464k1. FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ❑ 3.STRIKER PLATEIBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE 10 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONfi 469x. CONSTRUCTION MATERIAL ® L STEEL ❑ 4•FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CF,RTIFICATION: I certify that thi ys a is compatible with the hazardous substance stored and that the information provided herein is true, accurate,and i ull c it I r i ments. APPLICANT SIGNATURE DATE 10/4/2011 470' APPLICANT NAME(print) RO D ENRY APPLICANT TITLE CUST. SERV, COO A R 472 UPCF UST Rev.(12/2007)-1/2 www.unidocs.org m� v