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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 m 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: °J0' I DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 4 BUS ESS NAME=FACILITY NAME or DBA-Doing Business As) 3 L. 1^ BUS ESS SIT DURESS 103 CITY IN tJ'O AdLr II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATIOM TI PI TANK IS 434 3 ❑1.A STAND-ALONE TANK ©S ❑2.ONE M A COMPARTMENTED UNIT, Com tete one efor each com ammmtin daWe wmit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY INGA,Li7' S 436 NUMBER OF COMPARTMENTS IN THE UNIT 4n b III.TANK USE AND CONTENTS TANK USE Ie.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ I..AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE I] 4.HAZARDOUS WASTE(Includes Used Oil ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(.)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439. CONTENTS PETROLEUM: ❑ I..REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED e'Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Spei440. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ l 1.OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL fl 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL U 3.FIBERGLASS ❑ 6.INTERNAL BLADDER VW ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER S ci : a4a SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHERS i 445. OVERFILL PREVENTION ® I.AUDIBLE&.VISUAL ALARMS 2.BALLFLOAT 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 4W SYSTEM TYPE -I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636ao(3)j 458 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC IN ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Spwify): 4Na SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4Mb ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. PIPING/TURBINE CONTAINMENTSUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4Md VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT Lj L STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT I.STEEL 4.FIBERGLASS IO.WGIDPLASTIC 90.NONE 99.OTHER(Spwify) 464f 464n VR PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS C3 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Spicily) 4646 ae 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE [I OTHER(SPecify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 0 90,NONE 4641. RISER PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464j 464 I RISER SECONDARY CONTAINMENT ❑ ],STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 4Nk 4Nk1 FILL COMPONENTS INSTALLED L UCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE IS 1.SINGLE WALL ❑ 2.DOUBLE WALL O 3,NO DISPENSERS ❑ 90.NONE 469. CONSTRUCTION MATERIAL ❑ I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(S eci ) 4696. VIII. CORROSION PROTECTION STELL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSEDCURRENT ❑ 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. APPLICANT SIGNATURE f ,Q DATE 7� O 410 APPLICANT NAME(print) °71' APPLICANT TITLE 471 UPCF UST-B-IR (]},/11107)