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`INIFIED PROGRAM CONSOLIDATE' 2M UNDERGROUND STORAGE TAr�le OPERATING PERMIT APPLICATION - TANK INFORMATION (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, 11, 111,1 V, and IX below) 410 ❑ I. 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:. 431 DATE EXISTING UST DISCOVERED: albj, �° �,3-Gqj 430b I. FACILITY INFORMATION FACILITY ID # (Agency Use OWv) I BUSINESS N ME (Same as FACILITY NAME or DBA -Doing Business As) 3 BUSINESS SITE AI?D$ESS X03 CITY IDQ H. TANK DESCRIPTION TANK ID 432 0.i`k 1. TANK MANUFACTURER 433 (1a)'�lQu,Jr) (Jv� 1TANK CONFIGURATION: THIS TANK IS 434 1. A STAND-ALONE TANK ❑ 2. ONE M A COMPARTMENTED UNIT. Com lege one mefor each cment in the unit. DATST SYSTEM INSTALLED 435 r TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS TN THE UNIT 437 III. TANK USE AND CONTENTS TANK. USE ❑ In. MOTOR VEHICLE FUELING ❑ It MARINA FUELING ❑ Ic. AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE(Includ U.ed Oil) ❑ 5. EMERGENCY GENERATOR FUEL[HSC§2528 L5(c)I ❑ 6. OTHER GENERATOR FUEL 10 95. UNKNOWN ❑ 99. OTHER (Specify): 43% CONTENTS PETROLEUM: ❑ la. 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): *h Ow• -A 44N NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ❑ 11. OTHER NON -PETROLEUM (Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK 9 I. 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): 444a SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445 ® 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 445. OVERFILL PREVENTION El 1. AUDIBLE & VISUAL ALARMS ❑ 2.BALLFLOAT U 3. FILL TUBE SHUT-OFF VALVE 451, ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT / WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ® 1. SINGLE -WALLED [12. DOUBLE -WALLED ❑ 99. OTHER 460 SYSTEM TYPE ❑ 1. PRESSURE ❑ 2. GRAVITY 91 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR §263003A 458 PRIMARY CONTAINMENT ® LSTEEL ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER(Specify): a64a SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ & FLEXIBLE ❑ 10. RIGID PLASTIC 464h 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER(SpmiFy): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ZI I. SINGLE WALL El 2. DOABLE WALL ❑90. NONE 464d VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT LFI. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGIDPLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 4644 g69e1 VENT SECONDARY CONTAINMENT ❑ LSTEEL ❑ 4. FIBERGLASS ❑ 10. RIGIDPLASTIC ® 90. NONE ❑ 99.OTHER (Speeify) 4641, 4mf1 VR PRIMARY CONTAINMENT ❑ LSTEEL ❑ 4. FIBERGLASS ❑ 10. RIGIDPLASTIC & 90. NONE ❑ 99.OTHER (Specify) 4648 46_4ill VR SECONDARY CONTAINMENT ❑ LSTEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC 90. NONE ❑ 99.OTHER (Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ L SINGLE WALL ❑ 2. DOUBLE WALL 90. NONE 464r RISER PRIMARY CONTAINMENT ❑ I. STEEL ❑ 4. FIBERGLASS ❑ I0. RIGID PLASTIC 90. NONE ❑ W. OTHER (Specify) 4641 464' 1 RISER SECONDARY CONTAINMENT ❑ LSTEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC [(I 90. NONE ❑ 99.OTHER (Specify) 464k 464k] FILL COMPONENTS INSTALLED ❑ L SPILL BUCKET ❑ 3. STRIKER PLATE(BOTTOM PROTECTOR ❑ 4. CONTAINMENT SUMP 4510-c VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ❑ I. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS M 90. NONE. 469° CONSTRUCTION MATERIAL ❑ LSTEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 4696-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION 44$' IX. 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 legad requirements. APPLICANT SIGNATURE 4 DATE Qro 7 APPLICANT NAME (print) 1, i 17I. APPLICANT TITLE , y-, c4<�/ 4T LLl1.+� UPCF UST -B- 1/2 Rev. (12/2007)