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T -o 'NIFIED PROGRAM CONSOLIDATED f�� l..i UNDERGROUND STORAGE TANK- /if) Qj l Y 514 OPERATING PERMIT APPLICATION-TANK INFO TI N/(one form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,IL III,IV,and IX below) 430 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION El 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE `8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 BUSINE S NME(Sam"e1 as F CILITY NAME or DBA-Doing Business As) 3 BUSINFSS SITE AQDgESS l03 CITYba cks, loa HMKJ_-jj *]1400 II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 .A. / 191.A STAND-ALONE TANK l0.Y�C y /IO 016'16-w,p4 [:12.ONE IN A COMPARTMENTED UNIT. VV 1 Co leve one eforeuh com cot in thewit. DAT UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 bWil C III.TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ le.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includ Usd Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§828I.5(c)] ❑ 6.OTHER GENERATOR FUEL �d 95.UNKNOWN ❑ 99.OTHER (Specify): 439• CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5,JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (specify): L.11A.Vlown 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(S i : 4406 IV. TANK CONSTRUCTION TYPE OF TANK 19 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ® LSTEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): M4a SECONDARY CONTAINMENT ❑ LSTEEL [13.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 N 90.NONE ❑ 95.UNKNOWN [199.OTHER(Specify) 445. OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ® 1.SINGLE-WALLED [12.DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY 29 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§3636(.)(3)] 458 PRIMARY CONTAINMENT In I.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90,NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ LSTEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 90,NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 46ac PIPINGNURBINE CONTAINMENT SUMP TYPE 09 I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS Ej 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464, 464e1 VENT SECONDARY CONTAINMENT ❑ LSTEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC A 90.NONE ❑ 99.OTHER(Specify) 464f 464fl VR PRIMARY CONTAINMENT ❑ LSTEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC W 90.NONE ❑ 99.OTHER(Specify) 4648 464 1 VR SECONDARY CONTAINMENT ❑ LSTEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 01.SINGLE WALL [1 2.DOUBLE WALL90.NONE 4641. RISER PRIMARY CONTAINMENT LlLSTEEL El 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464) 464'I RISER SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 10 90.NONE ❑ 99.OTHER(Specify) 4Mk 464-1 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451.-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS W 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. LY. APPLICANT SIGNATURE 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 �1 470. 26 APPLICANT NAME(print) y} tj 411' APPLICANT TITLE / rr yy 472' U PCF UST-B-112 Rev.(12/2007)