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LEA _ « RECEIVE® <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK N����. MENTAL <br /> ENTA <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION�ne fcrp>rppr IVI A- IT <br /> ITYPEOFACTION (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 <br /> 6;-Z-1.NEW PERMIT 3.RENEWAL PERMIT ❑ CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE ..UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 61kikWokili4302 DATE EXISTING UST DISCOVERED: 430b <br /> FACILITY ID#(Agency Use Only) rte x I <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 <br /> (*Oz/-) <br /> BUSINESS SITE ADDRESS CITY 04 <br /> TANK ID <br /> (fZJ44/900 / Ev?�rTANK MANUFACTURER433 �� <br /> CONFIGURATION: THIS TANK IS 434 <br /> 1.A STAND-ALONE TANK <br /> o/ �< D <br /> El 2.ONE IN A COMPARTMENTED UNIT. <br /> e Complete one paFte for each com ament in the unit. <br /> DATE UST SYSTEM INSTALLED 1 435 TANK CAPAC _ G, L,LONS 436 NUMBER OF M TMENTS IN THE UNIT 417 <br /> TANK USEla.MOTOR VEHICLE FUELING ❑ry Ib.MARINA FUELING Ellc.AVIATION FUELING 439 <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL(HSC§25281.5(c)) <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 419a <br /> CONTENTS PETROLEUM: X IS.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 <br /> 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S eci 440a <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> 11.OTHER NON-PETROLEUMS eci / 1,(8± ( 440b <br /> OT .eek"' ,...,..,•:.w _. ;. <br /> TYPE OF TANK 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN ` 443 <br /> PRIMARY CONTAINMENT 4ErI.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL [13.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 <br /> 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify) 445a <br /> OVERFILL PREVENTION C1 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT h 3.FILL TUBE SHUT-OFF VALVE c 452. <br /> ❑ 4.TANK MEETS REQUIREMENTS FOARl EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT �QN` <br /> o T U -TiT <br /> 4.n <br /> PIPING CONSTRUCTION MI.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTIIER J 460 <br /> SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY &K 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR§2636(a)(3)) 458 <br /> PRIMARY CONTAINMENT L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a <br /> SECONDARY CONTAINMENT ❑ .STEEL. El 4.FIBERGLASS C38.FLEXIBLE ❑ 10.RIGID PLASTIC 464b <br /> 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c <br /> PIPNG/FURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 4644 <br /> I YFiNTy <br /> VENT PRIMARY CONTAINMENT I.STEEL 4.FIBERGLASS Lj 10.RIGID PLASTIC L1 90.NONE ❑ 99.OTHER(Specify) 464c <br /> 46441 <br /> VENT SECONDARY CONTAINMENT ElI.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC 0.NONE <br /> ❑ 99.OTHER(Specify) 464f <br /> 464n <br /> VR PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 0.NONE ❑ 99.OTHER(Specify) 4645 <br /> 464 1 <br /> VR SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS 10.RIGID PLASTIC 0.NONE ❑ 99.OTHER(Specify) 464h <br /> 464h1 <br /> VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL NONE 4641. <br /> RISER PRIMARY CONTAINMENT .STEEL 4.FIBERGLASS 10.RIGID PLASTIC jo 90.NONE 0 99.OTHER(Specify) 464j <br /> 4641 <br /> RISER SECONDARY CONTAINMENT I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 0.NONE 99.OTHER(Specify) 464k <br /> 464k1 <br /> FILL COMPONENTS INSTALLED 1.SPILL BUCKET U 3.STRIKER PLATE/BOTTOM PROTECTOR 0 4.CONTAINMENT SUMP _:j2Cr 451a-c <br /> :::.•. :;;�:� '�I%t Rm11� PE1�E �f�OLS: AI1�11`(�I) ,� »,x, <br /> x. <br /> CONSTRUCTIONTYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS 0.NO\'E 469. <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER S ecify 469b-c <br /> a::r <br /> j i A <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION >_ 448 <br /> 7. � ,: •W < x <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, <br /> and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE `/ 470 <br /> APPLICANT NAME(print) / ; v 471' APPLICANT TITLE <br /> UPCF UST-B-1/2 Rev.(12/2007) <br /> l3 <br />