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UNIFIED PROGRAM CONSOLIDATED FORM E. UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(onc form per UST) :: TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,11,111,IV,and IX below) 43 I.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ S.CHANGE OF INFORMATION �/I ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY M#(Agency Use Only) _ _ ( j r'7 < 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 BUSINESS STFEADDRESS l03CITY 104 11 H.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER a33 TANK CONFIGURATION:THIS TANK IS 434 ---- r--� 91.A STAND-ALONE TANK [12-ONE IN A COMPARTMENTED UNIT, V / Complczc® pagc fm cah CwqwwCut m tEc emit DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT ` 437 Y, "-/_j -t M.TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE ttvcitt&s Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281-5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN �B 99.OTHER (Specify): GTv- i w 439a CONTENTS PETROLEUM: ❑ I a.REGULAR UNLEADED ❑ Ic.MID(iRADE UNLEADED ❑ 1 b.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 ❑ 1 I-OTHER NON-PETROLEUM(S fv): � IV. TANK CONSTRUCTION TYPE OF TANK 1 I-SINGLE WALL ❑ 2_DOUBLE WALL ❑ 95-UNKNOWN 443 PRIMARY CONTAINMENT _Ig I.STEEL ❑ 3-FIBERGLASS ❑ 6-INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95-UNKNOWN ❑ 99.OTHER (Specify)- 444' SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6-EXTERIOR MEMBRANE LINER ❑ 7-JACKETED 445 ❑ 90.NONE ❑ 95-UNKNOWN ❑99-OTHER(S -fy): 445, OVERFILL PREVENTION ❑ I-AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3-FILL TUBE SHUT-OFF VALVE 452. Q 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 ❑ I.PRESSURE ❑ 2-GRAVITY ❑ 3.CONVENTIONAL SUC [ON ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)) 458 PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99-OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ I-STEEL ❑ 4-FIBERGLASS ❑ 8.FLEXIBLE ❑ I O.RIGID PLASTIC 464b ❑ 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 ❑ 10.RIGID PLASTIC ❑ 90-NONE ❑ 99.OTHER(Specify) 4 464e1 VENT SECONDARY CONTAINMENT ❑ I.STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99-OTHER(Specify) 464f 464f1 VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NOME ❑ 99-OTHER(Specify) 4648 464p,l VR SECONDARY CON'TATNMENT I-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 4641. RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90-NONE ❑ 99-OTHER(Specify) 464i 4611 RISER SECONDARY CONTAINMENT ❑ I-STEEL ❑4-FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90-NONE ❑ 99-OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED ❑ I-SPILL BUCKET ❑ 3-STRUCER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451 a-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1-SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90-NONE 4Ma CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 1 O.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bc VIII. CORROSION PROTECTION S"rEEL COMPONENT PROTECTION ❑ 2_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 DATE APPLICANT NAME(print) `` 471' APPLICANT TITLE 472 U ti J L`li 'li iti.ti)rZ UPCF UST-B-112 Rev.(1212007)