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Am Ah rn(l?� rt)12 r l bX P, gt UNIFIED PROGRAM CONSOLIDATED FORM "I�/�9/9912 / UNDERGROUND STORAGE TANK ( G`'� OPERATING PERMIT APPLICATION - TANK INFORMATION (one form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal, complete only this section and Sections I, 1I,111, IV, and IX below) 430 ❑ 1. NEW PERMIT ,eJ3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 431a DATE EXISTING UST DISCOVERED: 430b 1. FACILITY INFORMATION FACILITY ID # (Agency Use Only) ' -00 16 - 1 BIVISINESa NAME (Same as FACILITY NAME or DBA -Doing Business As)/j �� I O / ' C d S US l B NESS IT�DDR S 103 CITY /i /_ 104 ft S1 II. TANK DESCRIPTION TANK ID# Q,�/l.��I 432 T TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 Zl . A STAND-ALONE TANK NI -to 3 Od�/ �, L /O� L/V / J / ❑ 2.ONE IN A COMPARTMENTED UNIT. i t Complete one page for each com anment in the unit. DA E fl SYSTEM INSTALLED 4;5 TANK CAPPACI y IN GALLONS 436 NUMBER OF OMPARTMENTS IN THE UNIT 437 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 ❑ 99. OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la. REGULAR UNLEADED ❑ Ic. MIDGRADE UNLEADED ❑ Ib. PREMIUM UNLEADED 440 )�r_3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (S eci ): 440a NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ❑ 11. OTHER NON -PETROLEUM (Specify): 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL . DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT ❑ I. STEEL[1FIBERGLASS 6. INTERNAL BLADDER 444 ❑ 7. STEEL +INTERLINING ❑ 95. UNKNOWN ❑ 99. OTHER (S ecify): 444a SECONDARY CONTAINMENT ❑ 1. STEEL ,'3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445 ❑ 90. NONE ❑ 95. UNKNOWN [199. OTHER (S eci 445a ): OVERFILL PREVENTION ❑ 1. AUDIBLE & VISUAL ALARMS ❑ 2. BALL FLOAT 3. FILL TUBE SHUT-OFF VALVE 412 ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT / WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1. SINGLE -WALLED . DOUBLE -WALLED ❑ 99. OTHER 460 SYSTEM TYPE ❑ 1. PRESSURE GRAVITY . CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR §2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ I. STEEL off 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ I. STEEL 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464b ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE I. SINGLE WALL 2. DOUBLE WALL ❑ 90. NONE 464d VI. VENT, VAPOR REC VERY (VR) AND RISER/ FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I. STEEL 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1. STEEL4. FIBERGLASS ❑ 10. RIGID PLASTIC 90. NONE ❑ 99. OTHER (Specify) 464f 464fl VR PRIMARY CONTAINMENT ❑ 1. STEEL 4. FIBERGLASS ❑ 10. RIGID PLASTIC 90. NONE ❑ 99. OTHER (Specify) 4648 464g I VR SECONDARY CONTAINMENT ❑ 1. STEEL 4. FIBERGLASS ❑ 10. RIGID PLASTIC 90. NONE ❑ 99. OTHER (Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ I. SINGLE WALL AW2. DOUBLE WALL 90. NONE 464, RISER PRIMARY CONTAINMENT ❑ I. STEEL P -4 -FIBERGLASS ❑ 10. RIGID PLASTIC 90. NONE ❑ 99. OTHER (Specify) 4(,41 404j i RISER SECONDARY CONTAINMENT ❑ I. STEEL FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 4641, ');�-4. 464k1 FILL COMPONENTS INSTALLED SPILL BUCKET 3. STRIKER PLATE/BOTTOM PROTECTOR ❑ 4. CONTAINMENT SUMP 451a -c VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE I SINGLE WALL DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 46% CONSTRUCTION MATERIAL ❑ I. STEEL 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 4696-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION 448 IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurme, and in full compliance with legal requirements. AP I A 46IGNATURE DATE a APPLICANT NAME rint) 471. APPLIC NT TITLE UPCF UST -111 - 1/2 ReN . (12/200')