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Dec 12 08 03:45p John Johnson - 916-443-6225 p.3 <br /> %NO, lv/ �P <br /> UNIFIED PROGRAM CONSOLIDATED FORM -rAo 5i7q-SO <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) <br /> FTY E OF ACTION (Check one item only. For as UST perrunent closure or removal cotl5plele only this section and Sections L II,IR,IV,and IX below) UI <br /> 1,NEW PERMIT .�3.RENEWAL PERMIT ❑ 5.CI4ANGE OF INFORMATION <br /> 6.TEMPORARY UST CLOSURE ❑ 7.USTPERMANENT CLOSURE ON SITE S.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: am I DATE EXISTING UST DISCOVEREM i30' <br /> L FACILITY INFORMATION <br /> FACILITY m R(Agency Use Only) X1001 q4✓-7 <br /> BU�SESS(NAME(Sam as FACILITY AME or DBA•DoinS Business As) 5 <br /> R/I✓ f{rro r <br /> BUS CFE. D S / �> 1Q5 CFTY :w <br /> On SCO <br /> IL TANK DESCRIPTION <br /> TANK ID# .2 TANK MANUFACTURER43 <br /> 3 TANK CONFIGURATIQV:THIS TANK IS Oe <br /> ASTANO-ALOTETAMIt <br /> NINRTME <br /> rfnOr+,6ARTMENTEDhIN.RI. <br /> DATE TSPS INSTALLED 435 TANK CAPACITY IN GALLONS 656 NUMBER OF COMPARTMENTS IN THE UNIT 437 <br /> n <br /> IIL TANK USE AND CONTENTS <br /> TANK USE l4.MOTOR VEHICLE FUELING O Ib.MARINA FUELING 0 Ia.AV1ATIONFUELMG +is <br /> 3.CHEMICAL PRODUCT STORAGE C 4.HAZARDOUS WASTE(E.N&s Ue al) 0 S.EhOR(iHNCYGENERAMRPUELLe. Cbss2B1.5(g7 <br /> 0 6.OTHER GENERATORFUEL 0 95.I:NKNOWN 0 99.OTHER <ify): 43% <br /> CONTENTS PETROLEUM: 9.REGUfARUNLEADED O Ie.MIDGRADE UNLEADED 016.PREMIUM UNLEADED 440 <br /> 0 3.DIESEL 0 S.JETFUEL 0 6.AVIATION GAS <br /> 0 S.PEMOLEUM BLEND FUEL 0 9.OTHER.PETROLEUM (Specify): 440' <br /> NON.PFTTROLEUM_O T.LSEDOIL 0 10.ETHANOL <br /> 0 11.OTHER NON-PETROLEUMS(Specify); Um <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK [1 1.SINGLE WALL 2.DOUBLE WALL 095.UNKNOWN K3 <br /> PRIMARY CONTAINMENT 0LSTEEL K3.FIBERGLASS 06.INTERNAL BLADDER 444 <br /> 0 7.STEEL+INTERNAL LINING 0 95.UNK,NOWN C 99.OTHER Seecif): 4444 <br /> SECONDARY CONTAINMENT 01.STEEL .FIBERGLASS 06.EXTERIOR MEMBRANE LINER 07.JACKETED 445 <br /> .NONE 095.UNKNOWN 099.OTHER eclfr): 4.5. <br /> OVERFILL PRF.VENi1ON :.AUDIBLE&VISUALALARM9 BALLFLOAT 3.FILL TUBE SHUT-OFF VALVE 452. <br /> d.TANK MEETS REQUIRErAENTS FOR EXEMPTION FROM OVERFILL PREVCNTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPTNGCONSTKUC710N {]I. 1111 All .DOUBLEAVALLED El99.OTHER 4m <br /> SYSTBM TYPE 1.PAL-SSUBE 0 2.GRAVITY 0 3 CON'VENTIONALSUCTION 0 4.SAFE SUCTION InCCRlIM6(aX3) 459 <br /> PRIMARY CONTAINMENT fU LSTEIEL lFIBERGLASS C 8.FLEXIBLE 010.RIGIDPLASTIC 4N <br /> 0 co ONE <br /> 0 95.UNKYOW11 0 99.OTHER(Speciy): 4614 <br /> SECONDARY CONTAINMENT C I.STEEL K4.FIBERGLASS 0 9.FLEXIBLE [I 10.]UGIDPLASTIC 4M6 <br /> Cl 90.NONE 0 95.UNKNOWN 0 W.OTHER(Speeiy): 494c <br /> PIPINGTURBINE CONTAINMENT SUMP TYPE 0 1,SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 4614 <br /> VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT I.ST.L 4.FTEERGLASS LI 10,RIGID PLASTIC 0 90.NONE 0 99.OT9EE(Specify) Moe <br /> 454.1 <br /> VENT SECONDARY CONTAINMENT' M :.STEEL 4.FIBERGLASS IO.XIGIDPLASTTC 0 90.NONE 0 99.OTHER(Sorciy) 46U <br /> 4 <br /> VR PRIMARY CONTAINMENT 01.STEEL a.FIBERGLASS to.RIGID PLASTIC ❑ 90.NONE 4M 99.OTHER(Spaify) 4Ma , <br /> M5 <br /> VR SECONDARY CONTAINMENT El r.STEEL .FIBERGLASS ❑ 10.ALGID PLASTIC ❑ 90.14ONE 0 99.OTHER(SpecBy) <br /> 664: <br /> VENT,PIPING TRANSITION SUMP TYPE M I.SINGLE WALL IW2.DOUBLE WALL r 90.NO'.JE iM:. <br /> RISER PRIMARY CONTAINMENT 0 L STEELd. 1 <br /> FIBERGLASS to.RIGID PLASITC 0 90.NONE 99.OTHER(SWciy) +611 <br /> RISER SECONDARY CORT.4INMENT 1.STEEL 4,FIBERGLASS ❑ 10.RIGIDPLASTIC In 90.N0NE 0 99.OTHER(Specey) 464x ' <br /> FILL COMPONENTS INSTALLED LSPILLBUCKEi J.STRIN <br /> KERPLATEIBOTTOPROTECTOR 6 41 <br /> 4.CONTAiNMENTSUMp 45m.c <br /> VII.UNDER DISPENSER CONTAINMENT(UDC) <br /> COFSTRUCPIONTYPE 0 I.SINGLE WALL 2.DOUBLE WALL 0 3.NODISPENSERS ❑ 90.NONE 969a <br /> CON SfRUCTION MATERIAL 0 L STEEL 19,4.FIBEFULASS 0 10.RIGID PLASTIC 11 99.OTHERS i ) R96c <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIALANODE(S) 0 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448 <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this LST system is cc mpatble with the haaard0os substance stored and that the Information provided herein h trnq accurate, <br /> and ie fall compliance with legal rc utretnenls. <br /> APPLICANT SIGNAI URE DATE 175' <br /> 1zr �Z•0$ <br /> APPLICANT NAME(prin3) 471' APPLICANT TITLE 4T_ <br /> Pit Ll� <br /> UPCF UST-13-112 <br /> Rev.(1272007) <br />