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IED PROGRAM CONSOLIDATED FO
<br /> UNDERGROUND STORAGE TANK
<br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST)
<br /> TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,ll,111,IV,and IX below) 410
<br /> ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ® 5.CHANGE OF INFORMATION
<br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL
<br /> DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 430b
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<br /> r'^t.',4?(,1t:;�FACILITY;;INFO,R AT IONt�fi't�Ra%"';'rf.�. :��,..�,�_
<br /> FACILITY ID#(Agency Use Only) fTy�a .M1 I 1
<br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3
<br /> Grant Line Shell 136187
<br /> BUSINESS SITE ADDRESS 103 CITY 104
<br /> 2375 W.Grant Line Road Trac
<br /> TANK ID# l 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434
<br /> 4-Diesel Xerxes ®LA STAND-ALONE TANK
<br /> ❑
<br /> 2.ONE IN A COMPARTMENTED UNIT.
<br /> Complete one page for each com anment in the unit.
<br /> DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS M THE UNIT 437
<br /> 1991 12000
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<br /> TANK USE ® la.MOTOR VEHICLE FUELING [I lb.MARINA FUELING ❑ Ic.AVIATION FUELING 439
<br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)]
<br /> [j6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a
<br /> CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440
<br /> ® 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS
<br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a
<br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL
<br /> ❑
<br /> 11.OTHER NON-PETROLEUM(Specify): 440b
<br /> TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443
<br /> PRIMARY CONTAINMENT ❑ L STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444
<br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444&
<br /> SECONDARY CONTAINMENT ❑ L STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445
<br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): • 445a
<br /> OVERFILL PREVENTION ® I.AUDIBLE&VISUAL ALARMS J$2.BALL FLOAT 13 3.FILL TUBE SHUT-OFF VALVE 452•
<br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT
<br /> F, s,V,..PROpUCT/�� ASTEIPIIG§ OiSTRUGTIONs ,i�`,f� ,n�'., .` ;<<t:r_���� «' Y`:,.:I Y.�.",
<br /> PIPING CONSTRUCTION ❑1.SINGLE-WALLED ®2.DOUBLE-WALLED ❑99.OTHER 460
<br /> SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458
<br /> PRIMARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464
<br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464&
<br /> SECONDARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b
<br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c
<br /> PIPINGIfURBINE CONTAINMENT SUMP TYPE ® I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644
<br /> VI:.VE1VT VAPQR RECOVERYi( 'R).SND,RYSERF/FFILP,,IPE'PIPII�jG:CONSTRUUTION
<br /> VENT PRIMARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e
<br /> 464el
<br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641'
<br /> 464n
<br /> VR PRIMARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 44644
<br /> VR SECONDARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h
<br /> 464h1
<br /> VENT PIPING TRANSITION SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4641.
<br /> RISER PRIMARY CONTAINMENT ® I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464]
<br /> 464'1
<br /> RISER SECONDARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k
<br /> 464k1
<br /> FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATEBOTTOM PROTECTOR ® 4.CONTAINMENT SUMP 45la-c
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<br /> 1)IS_ PE _SFrR�'Q4`TI�INnTE�j�''(�y7m"C
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<br /> CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a
<br /> CONSTRUCTION MATERIAL ❑ L STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b-c
<br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ® 6.ISOLATION 448.
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<br /> IFIC T : I certify that this US ys em is compatible with the hazardous substance stored and that the information provided herein is true,accurate,
<br /> and in full com lian w' h legal requirements.
<br /> C IG T RE DATE 470.
<br /> 11/11/2009
<br /> CA T NAME(pr' t 47j" APPLICANT TITLE472.
<br /> Si le for She Pro(
<br /> US Shell Oil HS&E Coordinator
<br /> UI'CF UST-B-3/4 Rev.(12/2007)
<br />
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