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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) <br /> TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11,III,IV,and IX below) 430. <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. <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) I' <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3' <br /> C Stop# 5449 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 322 S. Center + Stockton <br /> H. TANK DESCRIPTION <br /> TANK ID# TANK MANUFACTURER 433, TANK CONFIGURATION:THIS TANK IS 434. <br /> tQ�S S '� Xerxes ® 1.A STAND-ALONE TANK Complete one page for each <br /> ❑ 2.ONE IN A COMPARTMENTED UNIT compartment in the unit. <br /> DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. <br /> N/A 20,000 <br /> III. TANK USE AND CONTENTS <br /> TANK USE ® la.MOTOR VEHICLE FUELING ❑ Ib.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 /> ❑ 6.OTI!ERJqENVAjOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a. <br /> CONTENTS PETROLEUM: REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440. <br /> DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUMS ect 440a. <br /> �...P_.. fY)i...... <br /> NON-PETROLEUM ❑ ?.USED OIL ❑ 10.ETHANOL <br /> ❑ 11.OTHER NON PETROLEUM(Specify): 4406' <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK __.-.._0 1 SINGLE WALL ® 2 DOUBLE WALL ❑ 95.UNKNOWN 443. <br /> ----- - ------- <br /> - __.. .._._........._. .. ..---..__ ...._._- <br /> PRIMARY CONTAINMENT [1 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 <br /> ❑ EG ❑ 95.UNKNOWN ❑ 99.OTHER S eci 444a <br /> 7.STEEL+INTERNAL LININ <br /> ( P fy)7 <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. <br /> ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER(S eci 445a <br /> _. ...... ....__._. ...._..--- .. -_ ._._._._ ................_ <br /> OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. <br /> 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑ 1.SINGLE WALL 2.DOUBLE WALL (]99 OTHER 460. <br /> ----- ._. .._.... ...._....... _.... ._ ..... .. - -- <br /> SYSTEM TYPE- 1 PRESSURE 0 2.GRAVITY C13 CONVENTIONAL SUCTION ❑-4 SAFE SUCTION[23 CCR§2636(a)(3)] 458 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. <br /> ❑ 90.NONE (] 95.UNKNOWN 99.OTHER(Specify)_ 464a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. <br /> ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER(Specify):S eci 464c. <br /> .P_.... :..... ...._ 464._. .__..._ <br /> PIPING/I'URBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL NONE <br /> VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464e1. <br /> _.._.... _._._ .... ....... _.. ... <br /> VENT SECONDARY CONTAINMENT ❑ 1 STEEL FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90 NONE ❑ 99 OTHER(Specify): q�fj: <br /> .__._....... - -- ---- - _.... ._.. __ . _... ---- <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL FIBERGLASS ❑ 10 RIGID PLASTIC NONE ❑ 99 OTHER(Specify): 464418. <br /> .._.................................1-._ ......_........_. .------.. .__ -- .. ..._. .. .._.._ .._. 46 <br /> VR SECONDARY CONTAINMENT ❑ 1 STEEL �(,4 FIBERGLASS ❑ 10 RIGID PLASTIC 90 NONE ❑ 99 OTHER(Specify): <br /> 4h. <br /> 464h 1. <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 464. <br /> _.......... __......._ _­_.... - _..... ..._ � <br /> RISER PRIMARY CONTAINMENT STEEL [:34.FIBERGLASS ❑ 10 RIGID PLASTIC/0 0 NONE ❑ 99 OTHER(Specify): 464iI. <br /> _ <br /> RI4641. <br /> SER SECONDARY CONTAINMENT [:1I.STEEL [14.FIBERGLASS^ ❑ 10.RIGID PLASTIC_® 90.NONE ❑ 99.OTHER(Specify): 464k1. <br /> FILL COMPONENTS INSTALLED ® I.SPILL ET BUCK3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a c. <br /> VII. UNDER DISPENSER CONTAINMENT (UDC) <br /> CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL NO DISPENSERS ❑ 90.NONE 469a. <br /> - ---_..... .- -....... ........-..... .. .._......._........_.. ._......- - _ - ..... _........__._ -- -._..._._ <br /> 4696. <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c. <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION NeV"" 448. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the infor mation provided herrn rs tr ue, <br /> accurate and in full compliance with legal requirements i <br /> APPLICANT SIGNATURE DATE tt////L_ 470. <br /> APPLICANT NAME(print) Allen FaaSS 471. APPLICANT TITLE California Compliance Mana tr 472 <br /> UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org <br />