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m UNIFIED PROGRAM CONSOLIDATED FORM ;430 UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per vs-0TYPE OF ACTION (Check one item only. Foran UST permanent closure or removal,complete only this section and Sections I,II,III,IV,and Dt below) I.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 DATE EXISTING UST DISCOVERED: 430b n J I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ I BUS S-NAW(Same as FACILITY NAME or DBA-Doing Business As) 3 BugmFm SrrE ADDRESS 103 CITY 104 II.TANK DESCRIPTION TANK ID# d 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 W.A STAND-ALONE TANK ZI� / 1 ❑2.ONE IN A COMPARTMENTED UNIT. Camplcw oat pagc for cath conqwwcut in the uniL DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN 436 NUMBER OF COMPARTMENTS IN THE UNIT V 437 III.TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(I.I d.Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL.[HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN M 99.OTHER (Specify): O-'F-(i ti!�w 439& CONTENTS PETROLEUM: ❑ I a.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ I b.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTNER PETROLEUM (specify): 440a 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 .d 1.STEEL ❑ 3_FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION ff 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ Z GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR§2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Spec ty): 464a SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4_FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4616 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99-OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2_DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ to.RIGID PLASTIC ❑ 9o.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.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) 464g 464RI VR SECONDARY CONTAINMENT ❑ I.STEEL. ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 9o.NONE ❑ 99.OTHER(Specify) 464b 464h VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464i. RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ ".OTHER(Specify) 464] 464'1 RISER SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 9D.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED ❑ I.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL. ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ ".OTHER(Specify) 469b< VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ Z SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448• IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full compliance with legal requirements. 470. APPLICANT SIGNATURE 471DATE l/ 1� li . 472. APPLICANT NAME(print) APPLICANT TITLE UPCF UST-B-1/2 Rev.(12/2007)