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a a 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 I,If,III,IV,and IX 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 DATE UST PERMANENTLY CLOSED: 430a 1 DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. CRLLC/76#5448 BUSINESS alLAWRESS 103. CITY 104. ne - C� Stockton II. TANK DESCRIPTION TANK ID#4 i 5�p �¢2 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS p p 434. / + �'( Xerxes ® LA STAND-ALONE TANK Complete one as e for each I ❑ 2.ONE 1N A COMPARTMENTED UNIT compartment in the wit. DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. N/A 15,000 I III. TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)) - - - 6 OTHER GENERATOR FUEL ❑ 95 UNKNOWN . 9 OTHER(Specify): 439a. _ _. . ...... ............. CONTENTS PETROLEUM: a.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED b.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5 JET FUEL 6 AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440& ...._.... ... . NON-PETROLEUM ❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443. -- ..__..._....- .._._._._.. -----....._.._..__............_...............-- --._._...-...----------------._.._........_.............._........_.._...._.._........._.............._.._..._...._............_.-................_._......__...__._.._._-....__._._._.....------- PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444& -- - - --- _........ ......... SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a. OVERFILL PREVENTION ❑ I.AUDIBLE&VISUAL ALARMS ';,2.BALL FLOAT _W3.FILL TUBE SHUT-OFF VALVE 452, TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIP........ .......... ----------- ..__.. _..__._ __-_._._. _...__. __. ._......_.__._.__. .. ..... ......... .. ........... .. _ ._..____. ..___--- _.- SYSTEM TYPE IN L PRESSURE ❑ 2_GRAVITY ❑ 3 CONVENTIONAL SUCTION ❑ 4 SAFE SUCTION[23 CCR§2636(ax3)] 458. PRIMARY CONTAINMENT ❑ 1.STEEL ® -4-- ❑ 8.FLEXIBLE ❑ ]0.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a. SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC a646. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. .._..._ .- -...... - - -._.._. -----............_... ...... ........_._ .._._.._.. PIPING/TURBINE CONTAINMENT SUMP TYPE ® L SINGLE WALL ❑ 2.DOUBLE WALL 0.NONE 464d . VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC [190.NONE ❑ 99.OTHER(Specify): 464e. 464e1. VENT SECONDARY CONTAINMENT I STEEL ® 4 FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90.NONE ❑ 99 OTHER(Specify): 464n _ - -. . ..._ . .___....... _. .. .. . ................ _._... 1-1.1-11--l-_..__- VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ l0.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): q46 I. & _............... _._._ .. .--... ...... ..... ....... VR SECONDARY CONTAINMENT ❑ 1 STEEL 4 FIBERGLASS ❑ 10 RIGID PLASTIC ® 90.NONE ❑ 99 OTHER(Specify): 464hl. - -- -..__ .._-. ...._ __ ...__..-. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 4641. __ ._.__.._.. ----- ------ ------- -------- -.. ._..._.__.... . ....._... . . .. ... ... - - ............... _ RISER PRIMARY CONTAINMENT 1.STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Speci 4641. fy): a6a'1. RISER SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 4641. FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET 3.STRIKER PLATEBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a c. VII. UNDER DISPENSER CONTAINMENT QjDQ CONSTRUCTIONT......... ...__... ...-......._..... .. .._.__._ .... .._..___ _................ __ ._.. .._..._. ..__......... ._........._._... .. ......._ ` _.. CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS 0.RIGID PLASTIC ❑ 99.OTHER(Specify) ', VIII. CORROSION PROTECTION ' STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES ❑ 4.IMPRESSED CURRENT .ISOLATION IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST syste m is compatible with the hazardous substance stored and that the infor mation provided herein is accurate and in full compliance with legal requirements. APPLICANT SIGNATURE l`L DATE �r �i�-.. 470. APPLICANT NAME(print) Allen Faass 471. APPLICANT TITLE California Compliance Manager UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org