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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one co m Per UST) TYPE OF ACTION (Check one item only, For an UST permanent closure or removal,complete only this section and Sections 1,II,III,IV,and IX below) 430 ❑ I.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: 43MDATE EXISTING UST DISCOVERED: 4J06 I. FACILITY[D#(Agency Use Only) FACULTY INFORMATION 7 gR IBUSINESS NAME(Same as FACILITY NAME or DBA-Doing BusinessAs) JBUS[ SS SITEADDRESSr ar C� 9�a�s ' IDESTANK ID#�� DLl �/ `U a32 TANK MANUFACTURER FIGURATION: THIS TANK IS 43411AND-ALONE TANK INA COMPARTMENTED UMT. DATE UST SYSTE INSTALLED 435 TANK CAPAC� GALLONS a erorm.hm entinauwit, EROFCO PARTMENTS IN THE UNIT 431 III.TANK USE AND CONTENTS TANK USE ❑ is.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ 3.CHEMICAL PRODUCT STORAGE ❑ I..AVIATION FUELING 439 ,(�4.HAZARDOUS WASTE ij dOil) ❑ 5.EMERGENCY GENERATOR FUEL(HSC§25281.5(.)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN CONTENTS PETROLEUM: . [1 99,OTHER (Specify): 439a ❑ isREGULA UUNLEADED 101NLEAD Ic,MIDGRADEUED ❑ 3.DIESEL ❑ 5.JET FUEL ❑❑ .AVIATION UNLEADED 490 ❑ 8.PETROLEUM BLEND FUEL GAS NON-PETROLEUM:B 7,USED OIL LJ 9,OTHER PETROLEUM (Specify):): 940a ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM S 449b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN PRIMARY CONTAINMENT ® I.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 4a3 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS 99.OTHER (S ❑ 90.NONE ❑ 6.EXTERIOR bIEMBRANE LINER ❑ 7.JACKETED q45 OVERFILL PREVENTION I.AUDIBLE&VISUAL ALARMS O 2.BALL FLOAT99. ERS J° 3 FILL TUBE SHUT-OFF VALVE 45. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT 52 V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED 2.DOUBLE-WALLED ❑99,OTHER SYSTEMTYPE ❑ LPRESSUREER Z.GRAVITY ❑ 3.CONVENTIONAL SUCTION PRIMARY CONTAINMENT 154.FIBERGLASS4.SAFE SUCTION 23 CCR§2636EJU)l 458 El 90.NONE .❑ S.FLEXIBLE ❑ I0RIGID PLASTIC 464 , ❑ 95.UNKNOWN ❑ 99OTHER(Specify): 464. SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4mb ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 46ac PIPINGl1'URBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL d 2,DOUBLE WALL ❑ 90.NONE VI.VENT,VAPOR RECO RY p` 4b44 VENT PRIMARY CONTAINMENT I.STEEL 4.FIBS ERGLpASNSD oSER GIID PLA IPE PIPING CONS PTC 4� VENT SECONDARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC 464`1 ❑ 90.NONE ❑ 99.OTHER(Specify) 4mf VR PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC90.NONE 99.OTHER(Specify) 4mn VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 4M 1 ® 90.NONE 99.OTHER(Specify) 4mh VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 464h1 RISER PRIMARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 4M` ❑ 90.NONE 99.OTHER(Specify) 464j RISER SECONDARY CONTAINMENT ❑ I.STEEL 0 4.FIBERGLASS I10.RIGID PLASTIC 90.NONE 469 I ❑ 99.OTHER(Specify) 464k FILL COMPONENTS INSTALLED ❑ L SPILL BUCKET 3.STRIKER PLATFIBOTTOM PROTECTOR 4,CONTAINMENTSUMP 45�-c VII.UNDER DISPENSER CONTAINMENT(ram•) CONSTRUCTION TYPE NI.SINGLE WALL El Z.ODUBLE WALL [13.NO DISPENSERS CONSTRUCTION MATERIAL LJ I.STEEL 0 -FIBERGLASS ❑ 10.RIGID PLASTIC NONE 969a ❑ 99.OTHER(Specify) 9691-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2,SACRIFICIAL ANODE(S) g 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. M. APPLICANT SIGNATURE CERTIFICATION: I certify th thin U sys is compatible with the hazardous substance stored and that the Information provided herein is true,accurate, sad In fu m I al requirements. APPLICANT SIGNATURE DATE 410. Z t-m APPLICANT NAME(print)l? 471. APPLICANT TI tie-471 b UPCF UST-B-I12 '�1„ Rev.(1212007)