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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one firm per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,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 El 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4312, DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) t BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) BIJSINESASI $ADDRE N T L J �� ,y b 103 C[TYV 104 (� II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 ////y► ` 1 Do A STAND-ALONE TANK 74-0&15,33 � A Complete ONE IN A COMPARTMENTED UNIT. one page for each mm est in the=L DATE UST SYSTEM INS L 435 TANK CAPPTIIN G LONS 436 NUMBER OF COMPAfTMENTS IN THE UNIT 437 ly III.TANK USE AND CONTENTS 1 TANK USE 10 la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED Wjb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL I 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL 15 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ff 95.UNKNOWN [199.OTHER(Si ): 445a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS El 2.BALL FLOAT X 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVER PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 1.SINGLE-WALLED 15 2.DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR§2636(a)(3)] 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 19,8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGITURBINE 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 Pj 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE C 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT 0 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0,90.NONE 0 99.OTHER(Specify) 464f 464Fl VR PRIMARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS El10.RIGID PLASTIC C190.NONE [199.OTHER(Specify) 4646 464 I VR SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC Q 90.NONE 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE I.SINGLE WALL ❑ 2.DOUBLE WALL NONE 464L RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE Lj 99.OTHER(Specify) 4641 464'I RISER SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC PF90.NONE 99.OTHER(Specify) 464k 4641 FILL COMPONENTS INSTALLED Ir 1.SPILL BUCKET 0 3.STRIKER PLATE/BOTTOM PROTECTOR Q 4.CONTAINMENT SUMP 45Ia-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE fg�_1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL 0 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696,- VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 445. IX. APPLICANT SIGNATURE CERTIFICATION: 1 ce y that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and' full compliance with legal re uirements. APPLICANT SIGNATU DATE 1 / 470 APPLICANT NAME(print) � 471' APPLICANT[TITLE / 1l 472. UPCF UST-B-1/2 (12/2007)