BILLING - Laserfiche WebLink

Home Browse Search

11 luI1 {� UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK 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,II,III,IV,and IX below) 430 1.NEW PERMIT El3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION [16.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE [18.UST REMOVAL DATE UST PERMANENTLY CLOSED: 43°' DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION 1145 FACILITY ID#(Agency Use Only) - _ i :? lI BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) ({� BUSINESS SITE ADDRESS 103 CITY 104 H.TANK DESCRIPTION TANK ID 4 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 _ 1.A STAND-ALONE TANK /\ I ( � ❑2.ONE IN A COMPARTMENTED UNIT. 1 v w Cmnplm arc for me6 m the=L DATE UST SYSTEM INSTALLED 435 TANK CAP SIN GALLONS 436 NUMBER OF COMPARTMENTS N THE UNIT 437 III.TANK USE AND CONTENTS TANK USE ❑ la MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Indodes Used 00) ❑ 5.EMERGENCY GENERATOR FUEL.[HSC§25291.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ga 99.OTHER (Specify): C-'--L+ .- ,�,; 439a CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ IC.MJDGRADE UNLEADED ❑ Ib.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): 4a0b IV. TANK CONSTRUCTION TYPE OF TANK 4g 1.SINGLE WALL ❑ 2-DOUBLE WALL ❑ 95.UN"OWN 443 PRIMARY CONTAINMENT a 1.STEEL ❑ 3_FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99-OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ I.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION ❑ L AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. [ 4.TANK MEETS REQUIRMAENTS FOR EXEMPTION FROM OVERFILL PRE/=ON EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99-OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2 GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4_SAFE SUCTION[23 CCR§2636(.x3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑4_FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4464 VENT SECONDARY CONTAINMENT ❑ I_STEEL ❑4.FIBERGLASS ❑ I0.RIGID PLASTIC ❑ 90.NONE ❑ 99-OTHER(Specify) 461f 4641 VR PRIMARY CONTAINMENT l.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464gl 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 ❑ 2-DOUBLE WALL ❑ 90.NONE 464L RISER PRIMARY CONTANMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 1 o_RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 1 RISER SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90-NONE ❑ 99-OTHER(Specify) 464k 464k FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4-CONTAINMENT SUMP 451a-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.RIGTD PLASTIC ❑ 99.OTHER(Specify) 469b c VIII. CORROSION PROTECTION STEEL.COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IR. 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 i DATE APPLICANT NAME(print) 471' APPLICANT TITLE 472. UPCF UST-B-1/2 Rev.(12/2007)