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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFO EVED TYPE OF ACTION (Check ooe Item only. For w, UST permanent closure or removal, complete only this section and Sections; IL III, IV, and IX below) a3n 0 1. NEW PERMIT 3. RENEWAL PERMIT D 5. CHANGE OF INFORM b 6. TEMPORARY UST CLOSURE LI 7. UST PERMANENT CLOSURE ON SITE 8. UST REMOVAL V 9 Z 6 DATE UST PERMANENTLY CLOSED: d30a DATE EXISTING UST DISCOVERED: 4306 L FACILITY INFORMATIOI+i FACILITY ID # (Agency Use Only) r DEATM T' BUSINESS NAME (Saute as FACILITY NAME or DBA- Ing Business As) 1 3 PC Uts VrjvI3i G}VM\j 2353 T 0 520 t 12 LI" BUSISS,S AD 1 I93 // ; _ZVA O t...AtOVE. CITY IN LOL�I n�IWI)V Ii. TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 43.3 TANK CONFIGURATION: THIS TANK IS 434 Ca1-T'AINPA ENT- 1.ASI'AND-ALONE TANK SOLX)1101� �2.ONE INACOMPARTMENTED UNT. CnPide me forte m9he Inti[ DATE UST SYS1E INSTALLED 435 TANK CAP TTY ALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT a33 s , a III. TAW USE AND CONTENTS TANK USE / la. MOTOR VEHICLE FUELING ❑ Ib. MARINA FUELING D Ic. AVIATION FUELING 439 0 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (I aW Used Oil) D 5. EMERGENCY GENERATOR FUEL[ BSC ¢25281.5(c)] 0 6. OTHER GENERATOR FUEL 0 95. UNKNOWN 0 99. OTHER (Specify): a39, CONTENTS PETROLEUM: ❑ la REGULAR UNLEADED 0 Ic. MIDGRADE UNLEADED 0 Ib. PREMIUM UNLEADED 44o N 3. DIESEL 0 5. JET FUEL 0 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL D 9. OTHER PETROLEUM (S 440, NON-PETROLEUM: 0 7. USED OI, 0 10. ETHANOL ❑ 11. OTBERNON-PETROLEUM(S ): 4406 M 'T'AiNWC I RHC TYPE OF TANK ❑ 1. SINGLE WALL 10 2. DOUBLE WALL [195. UNKNOWN 43 PRIMARY CONTAINMENT ❑ I. STEEL 0 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 ❑ 7. STEEL+ INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 444 SECONDARY CONTAINMENT ❑ i. STEEL 18 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 443 0 90. NONE 0 95. UNKNOWN 099.OTHER (S )_ 45a OVERFILL PREVENTION E 1. AUDIBLE & VISUAL ALARMS ❑ Z BALL FLOAT E 3. FILL TUBE SHUT-OFF VALVE a52. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/ WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION D 1. SINGLE-WALLED 2 2. DOUBLE-WALLED ❑ 99. OTHER 460 SYSTEM TYPE M 1. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION 0 4. SAFE SUCTION [23 CCR §W36(a)(3)j 458 PRIMARY CONTAINMENT ❑ 1. STEEL ■ 4. FIBERGLASS ❑ S. FLEXIBLE 0 10. RIGID PLASTIC 46a 0 90. NONE 0 95. UNKNOWN 0 99, OTHERS ): 464 SECONDARY CONTAINMENT ❑ 1. STEEL N 4. FIBERGLASS ❑ S. FLEXIBLE 0 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN 0 99.OTHER (Spadly): 464 PIPINGTMINE CONTAINMENT SUMP TYPE ❑ I. SINGLE WALL 0 2. DOUBLE WALL 090_NONE 46/d VF €� VAPOR RECOVERY (VR) AND RiSERIFILL PIPE PIPING CONS'#'RI.KnON VENT PRIMARY CONTAINMENT ❑ L STEEL M 4. FIBERGLASS 0 10. RIGID PLASTIC 0 90. NONE 0 99 OTHER (Specify) 4Me 4641 VENT SECONDARY CONTAINMENT 0 I. STEEL 4 4. FIBERGLASS 0 10. RIGID PLASTIC ❑ 90.90W 0 99. OTHER (SPec*) 464f 4 fl VR PRIMARY CONTAINMENT ❑ I. STEEL 4. FIBERGLASS ❑ 10. RIGID PLASTIC F 90. NONE 99. OTHER (Specify) 464s 464 l VR SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS El 10. RIGID PLASTIC ®90. NONE 99. OTHER (Spaify) 4646 46/61 VENT PIPING TRANSITION SUMP TYPE ❑ L SINGLE WALL 2. DOUBLE WALL 90. NONE 4641. RISER PRIMARY CONTAINMENT 9 L STEEL 0 4. FIBERGLASS 10. RIGID PLASTIC 0 90. NONE ❑ 99, OTHER (Specify) 464j 464't RISER SECONDARY CONTAINM WIf I. STEEL. 4. FIBERGLASS 0 10. RIGID PLASTIC a 90. NONE 99. OTHER (Specify) 4641 464k1 FILL COMPONENTS INSTALLED I. SPILL BUCKET 3. STRIKER PLATE/BOTTOM PROTECTOR 4. CONTAINMENT SUMP 451. VIL T3ALDER B�C�1'I•{IIDeq CONSTRUCTION TYPE ❑ 1. SINGLE WALL 0 2. DOUBLE WALL 0 3. NO DISPENSERS 0 90. NONE a69a CONSTRUCTION MATERIAL 0 1. STEEL N 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Spec ) 469bc Vila. CORROSIONTROTECTION STEEL COMPONENT PROTECTION . ❑ 2. SACRIFICIAL. ANODE(S) 0 4. IMPRESSED CURRENT 0 6. ISOLATION "s. M APPLICANT SIGNATURE CERTIFICATION: I certify that this T system is compatible with the hazardous substance stored and that the information provided herein 4s true, accurate, and in fab cma - with Legsq requiremeuts APPLICANT SIGNATURE DATE °30 APPLICANT NAME (priltt S a71. APPLICANT TITLE r .F cN 472- UPCF UST -B -12 Rev. (12/2007)