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UNIFIED PROGRAM CONSOLIDATED FORM 6*1 UNDERGROUNDSTORAGETANK 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,H,III,TV,and IX below) 430 NEW PERMIT ❑ 3-RENEWAL PERMIT [15.CHANGE OF INFORMATION El6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE El8.UST REMOVALDATE UST PERMANENTLY CLOSED_ 430a DATE EXISTINGUSTDISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) - - l{ 1124 ' BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 BUSINESS SITE ADDRESS 103 CITY 104 II.TANK DESCRIPTION TANK ID# W 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 91-A STAND-ALONE TANK ❑2.ONE IN A COMPARTMENTED UNIT. Conplac aaepap fat tach wuqwwcnt m the unit DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN WyIISI 4 3 NUMBER OF COMPARTMENTS IN THE UNTIT 437 �/l�(l III.TANK USE AND CONTENTS TANK USE ❑ 1 a.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ 1 c.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE llnchtdes Uwd Oil) ❑ 5-EMERGENCY GENERATOR FUEL[IISC§252SL54c)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN $ 99-OTHER (Specify): ,f w 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ I b.PRLMJUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER 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 I.STEEL ❑ 3-FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.L?dKNOWN ❑ 99.OTHER (Specify): 444. SECONDARY CONTAINMENT ❑ 1.STEEL. ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99-OTHER(Specify): 445. OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452- 8 4.TANK MEETS REQUMEMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑I.SINGLE-WALLED ❑2-DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2-GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4-SAFE SUCTION[23 CCR§2636(a)(311 458 PRIMARY CONTAINMENT ❑ L STEEL. ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4Mi SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8-FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL, ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI-VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I-STEEL ❑ 4.FIBERGLASS ❑ 10-RIGID PLASTIC ❑ 90-NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ I-STEEL- ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99-OTHER(Specify) 464E 464Fl VR PRIMARY CONTAINMENT ❑ 1.STEEL. ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NOME ❑ 99 OTHER(Specify) 4648 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4641• RISER PRIMARY CONTAINMENT ❑ I.STEEL ❑4.FIBERGLASS ❑ l0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 464'1 RISER SECONDARY CONTAINMENT ❑ 1 STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 4641 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3-STRIKER PLATUBOTTOM PROTECTOR ❑ 4-CONTAINMENT SUMP 451ac VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WAIT ❑ 3-NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGTD PLASTIC ❑ 99-OTHER(Specify) 469b- VIII. CORROSION PROTECTION STEEL.COMPONENT PROTECTION ❑ Z SACRIFICIAL ANODE(S) ❑ 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 DATE APPLICANT NAME(print) �� 471 APPLICANT TITLE 47z Z UPCF UST-B-1/2 Rev.(12/2007)