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a 0 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one trent only. For a UST closure or removal,complete only this section and Sections 1,II,111,IV,and BYhelou) 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: 4301). I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ 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# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434• 39000213148 0 7897 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 12,000 III, TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ 1c.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil ❑ 5.EMERGENCY GENERATOR FUEL[HSC g25281.5(c)) ❑ 6.OTHER -- GENERATOR FUEL _ ❑ 95.UNKNOWN ❑ 99.OTEIFR(Specify): 439a. CONTENTS PETROLEUM: la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED - ❑ Ib.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS 8.PETROLEUM BLEND FUEL ❑ 9,OTHER PETROLEUM fy _TROLEUM(Speci - 440s. 10 NON-PETROLEUM:❑ 7•USED OIL -�- - ❑ . THAN EOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4401). 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.1.INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444e. SECONDARY CONTAINMENT ❑ I.STEEL ""'••-" C33.FIBERGLASS [16•EXTERIOR MEMBRANE LINER ❑ 7.JACKETED - -445- ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445x. OVERFILL PREVENTION " ❑ I.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT C13,FILL,TUBE SHUT-OFF VALVE _ 45Z ' ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL,PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 0 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 99,OTHER _ 460. SYSTEM TYPE ® 1.PRESSURE --❑ 2.-&R- --�-❑ 3_CONVENTIONAL SUCTION -❑ 4,SAFE SUCTION[23 CCR_¢2636(a)(3)I- - 458. PRIMARY CONTAINMENT--❑ I.STEEL ® 4,FIBERGLASS ❑ 8.FLEXIBLE ❑ ]0.RIGID PLASTIC 464. _ __ _ ❑ 90.NONE _❑ 95.UNKNOWN [399.OTHER(Specify): 464x. ^SF,CONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS _❑ 8.FLEXLBLE - ❑ 10.RIGID PLASTIC4546." ❑ 90.NONE ® 95.UNKNOWN_ ❑ 99.OTHER(Specify)_ 464c. PIPING/TURBINE CONTAINMENT SUMP TYPE _. ® t.SINGLE,WALL p 2.DOUBLE WALL ❑ 90.NONE VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4•FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ® 99.OTHER(Specif 464e. Y) UNKNOWN 464cl. VENT SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ® 99.OTHER(Specify):UNKNOWN a64n. -----.-----.---.._......_.__....._-._..._.._.._._,.._..___.....___-.....___-- _ VR PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ® 99.OTHER(Specify): 4649 UNKNOWN 46a$i._ VR SECONDARY CONTAINMENT ❑ I.STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC (j90,NONE ® 99.OTHER(Specify):UNKNOWN 46hI VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90,NONE 464i. RISERRISER PRIMARY CONTAINMENT ❑ 1.STEEL. [14.FIBERGLASS ❑ 10.RIGID PLASTIC [1 90^NONE -® 99.OTHER(Specify):UNKNOWN _446-4' RISER SEON CDARY CONTAINMENT C1 1.STEEL [:14.FIBERGLASS [j10.RIGID PLASTIC [190.NONE ® 99.OTHER(Specify):UNKNOWN 46hk. FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET _ ❑ 3.STRIKER-PLATE/BOTTOM PROTECTOR -❑ 4.CONTAINMENT SUMP 45la`c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® I.SINGLE WALL �2_DOUBLE WALL.-_-_ 3.NO DISPENSERS ❑ 90,NONE 469x. CONSTRUCTION MATERIAL ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION A48• IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify thatt T s st is compatible with the hazardous substance stored and that the information provided herein is true, accurate,and i f 11 c li c wi h IE, 1 requirements. APPLICANT SIGNATUR 77DATE 10/4/2011 470' APPLICANT NAME(print) ROH A HENRY 471. APPLICANT TITLE CUST. SERV. COORDINATOR 472. UPCF UST-B Rev.(12/2007)-t/2 www.unidocs.org