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_ 1 IFIED PROGRAM CONSOLIDATED '}B I"') I UNDERGROUNDSTORAGETANK I� OPERATING PERMIT APPLICATION-TANK INFORMATION(One form OPERATING UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this s cion and Sections 1,Il,III,IV,and IX below) 430 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL. DATE UST PERMANENTLY CLOSED: 4}O81 DATE EXISTING UST DISCOVERED: anon I. FACILITY INFORMATION FACILITY ID 0(Agency Use Only) A _ l� L> _ 9 ('� -7 BUSINESS NAME(Same as FACILI NAME or DBA-Doing Business f� 7 (), �1 i BUSINESS SITE ADDRESS CPfY 104 ADDRESS.. ( , U.TANK DESCRIPTION �TANK ID �yns o'So 4�q 433 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS'TANK IS 434 U &O a1.ASEAN D-ALONE 1 y� V.,] ❑2.ONE INA COMPARTMENTEDachcmp UNIT. Com lHe one for each com eot in the unit. DATE UST SYSTEM INSTALLED 435 TAN 4Q6PACITI:IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 I.((TIIAVVNKUSE AND CONTENTS TANK USE I a.MOTOR VEHICLE FUELING ❑ If.MARINA FUELING ❑ Ic.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used 0d) ❑ 5,EMERGENCY GENERATOR FUEL[HSC§25281.5(c)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439. CONTENTS PETROLEUM: la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): a4oa NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11,OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAMMENT ❑ 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444° SECONDARY CONTAINMENT ❑ 1.STEEL W.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify)+- 45. OVERFILL PREVENTION 0 1.AUDIBLE&VISUAL ALARMS U 2.BALL FLOAT CL 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ I.SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR 12636( 3)] 458 PRIMARY CONTAINMENT ❑ I.STEEL 1.4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL 9L 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(SpecifyI 464c PIPMGfI'URBINE CONTAINMENT SUMP TYPE 1,SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4o4d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I.STEEL In 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS 10.RIGIDPLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT El L STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4648 4&1.1 VR SECONDARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC El 90.NONE 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 1.SMGLE WALL 2.DOUBLE WALL 90.NONE 4641 RISER PRRvtARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464) 464'1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) �W_' a kl FILL COMPONENTS INSTALLED 1.SPILL BUCKET 0 3.STRIKER PLATFJBOTTOM PROTECTOR ❑ 4.CONTTrW ENT SUMP ( .v$ 451a-c VIL UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE ,; - 469. CONSTRUCTION MATERIAL L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b< VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION EF-311 448_ IX. APPLICANT SIGNATURE m 's . CERTIFICATION: I cerfify that this UST system is compatible with the hazardous substance stored and that the informatio ro ded he iurate, and in full compliance with legalrequirements. APPLICANT SIGNATURE �!(� 11- DATE 31111 Z ' •... .. �� _.470. APPLICANT NAME(print) ll`' S 14d J, P- M 14 R 471- APPLICANT TITLE MAR 14201Z 472_ JOr,.RJiN COUP. .- '"NIP ONNIENIAL ir:.ni-fH F?.n`Re0:VY212007) UPCF UST-B-I/2