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�IFIED PROGRAM CONSOLIDATED F� O` UNDERGROUND STORAGE TANK 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,IV,and IX below) 430 ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a 1 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 ec>57co G 9S 3 Tn-npn/ or /v3 / BUSINESS SITE ADDRESS 103 2 440 D e IS St., CITY 04 II.TANK DESCRIPTION TANK ID# 44332 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 4 b5l �C/I I11 �� / /�� /u � O.ONE IND-ALONE TANK ARTME I Ir(�I 7 C� b N U �/ 2.ONE M A COMPARTMENTED UNIT. Co leh one aefor eacM1 mm amnent in the unit DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 q«yu Sl 2vo $ 30, vP� On e III.TANK USE AND CONTENTS TANK USE 19 Ia.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: Ia.REGULAR UNLEADED ❑ ]c.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 44n 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 449a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM S ccifv: 44ab IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL X2.DOUBLEWALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL M 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S ci ): 444a SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER(S eci ): 445. OVERFILL PREVENTION1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT EI 3.FILL TUBE SHUT-OFF VALVE 452, 4.TANK MEETS REQUIREMENTS F R EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION1.SINGLE-WALLED 2.DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ .GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(a)(3)1 458 PRIMARY CONTAINMENT ❑ 1.STEEL IA 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING,TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL _W 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464. 464.1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 464fJ VR PRIMARY CONTAINMENT ❑ 1.STEEL �0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 4Mg] VR SECONDARY CONTAINMENT ❑ 1.STEEL Pt 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4647 RISER PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 464'1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATEBOTTOM PROTECTOR 4.CONTAINMENT SUMP 45la-c VII.UNDER ISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4691,c III. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT Pr 6.ISOLATION 448. 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 legal requirements. APPLICANT SIGNATURE DATE c p q 470' APPLICANT NAME(print) ( e/ynf J �JG/ 477 APPLICANT TITLE UPCF UST-B-112 4 /// Rev.(12/2007)