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LEA Cak dG i G �i L.Lam. \0 MAR 10 2016 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK ".N V I RONME TA OPERATING PERMIT APPLICATION-TANK INFORMATION(one forth peg US1j 11Tli,"1=19T 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 �`l.NEW PERMITL] 3.RENEWAL PERMIT CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE ❑ ..UST REMOVAL DATE UST PERMANENTLY CLOSED: Q N 430a DATE EXISTING UST DISCOVERED: / 430b FACILITY ID#~(Agency Use Only) IND""" v - 1 c w"T". BUSINESS NAME(Same as FACILITY NAME or QBA-Doing Business AS) 3 L �� iJllr BUSINESS SITE ADDRESS 1 /� L �f� CITY / too s.r ' TANK ID F �1��i4/ � { 2 433 TANK MANUFACTURER TALC CONFIGURATION: THIS TANK IS 434 ,Kl.A STAND-ALONE TANK ❑2.ONE IN A COMPARTMENTED UNIT. !/ Complete one page for each com anent in the unit. DATE UST SYSTEM I �� 43s TANK CAPAC �C LONS 436 NUMBER OF M TMENTS THE UNIT 437 TANK USE Xla.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc.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): 439. CONTENTS PETROLEUM: CK la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 1.OTHER NON-PETROLEUMS eci 440b e T " 4 M,. Q .6TliV TYPE OF TANK jal.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT .STEEL ❑ 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 ❑ 95.UNKNOWN ❑99.OTHER(Specify) 445a OVERFILL PREVENTION_ 1.AUDIBLE&VISUAL ALARMS 0 2.BALL FLOAT 6 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT i1/O�U4� y� a PIPING CONSTRUCTION al.SINGLE-WALLED [12.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(aX3)) 458 PRIMARY CONTAINMENT 1.STEEL [14.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. SECONDARY CONTAINMENT ❑ .STEEL. [:14.FIBERGLASS El8.FLEXIBLE C310.RIGID PLASTIC 464b 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL90.NONE 464d .. , �_a � ��, VENT PRIMARY CONTAINMENT 1.STEEL U 4.FIBERGLASS Ll 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS C3 10.RIGID PLASTIC 0.NONE 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT 0 I.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 0.NONE t3 99.OTHER(Specify) 4645 464 1 VR SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS 10.RIGID PLASTIC0.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE El I.SINGLE WALL 2.DOUBLE WALL .NONE 4641. RISER PRIMARY CONTAINMENT .STEEL 4.FIBERGLASS 10.RIGID PLASTIC jC)sA.NONE 0 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC fl0.NONE 99.OTHER(Specify) 464k 4601 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATEBOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 45la-c CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO'DISPENSERS 0.NONE 469. CONSTRUCTION MATERIAL L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 99.OTHER'S i.W, 469b-c r °h • . Y ._Vil STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. 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 DATE l� ` / 470. APPLICANT NAME(print) Z//Zr! 471' APPLICANT TITLE ,/� /J �� 472 UPCF UST-B-I/2 Rev.(12/2007) � 3