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r: 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,II,III,IV,and IX below) 430 ®, 1.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: 430i ��I//'�'I�j T I. FACILITY INFORMATION 'CI' FACILITY ID#(Agency Use Only) BUSINESS (Same as FACMI TY NAME or DBA-Doing Business As) 3 ADDRESS 103 CITY _ los H.TANK DESCRIPTION TANK ID# (r) 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 [RI.A STAND-ALONE TANK ❑2-ONE IN A COMPARTMENTED UNIT. A) lac we pagc feu ach coapamum m the=L DATE IST SYSTEM INSTALLEb 1 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 Y,) I `4 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 t1mWdm1J d Oil) ❑ 5.EMERGENCY GENERATOR FUEL JIM§75281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN 99.OTHER (Specify): �*�_ - w 439a CONTENTS PETROLEUM: ❑ la REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL 9.OTHER PETROLEUM ): -1,: 440. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 1 I.OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION TYPE OF TANK 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95_UNKNOWN _ 443 PRIMARY CONTAINMENT -9 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95_UNKNOWN ❑ 99.OTHER (specify): 444. SECONDARY CONTAINMENT ❑ 1.STEEL [13.FIBERGLASS ❑ 6.ETTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTTrER(specifvy 445a OVERFILL PREVENTION ❑ 1_AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. a 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 ❑ 2-GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(aX3)1 458 PRIMARY CONTAINMENT ❑ T.STEEL ❑ 4.FIBERGLASS ❑ 8.iZE}QBL.E ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4&4b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99-OTHER(Specify): 464c PIPINGrFURBINE CONTAINMENT SUMP TYPE ❑ I-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 ❑ 979.OTHER(Specify) 4441 464e1 VENT SECONDARY CONTAINMENT ❑ 1_STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 4646 464gl VR SECONDARY CONTAINMENT ❑ 1.STFET. ❑ 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 464i. RISER PRIMARY CONTAINMENT I_STEEL El 4.FIBERGLASS ❑ lo_RIGID PLASTIC ❑ 90.NON TE ❑ 99 OTHER(Specify) 464) 464il RISER SECONDARY CONTAIN&Wr E] 1_STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 46411 46411 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIPER PLATIJBOTTObI PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT(DDC) CONSTRUCTION TYPE ❑ I.SINGLE WALL ❑ 2_DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Spcc-ify) 4694{ VIII. CORROSION PROTECTION STEEL 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 fun compliance with legal requirements. 470. APPLICANT SIGNATURE DATE APPLICANT NAME(print) 471. APPLICANT TITLE 472. V UPCF UST-B-1/2 Rev.(1212007)