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TGF � o UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check ane item only. For a UST closure or removal complete only this section and Sections 1.A 111,IV.and IX below) 430. ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 0 7.UST PERMANENT CLOSURE ON SITE YRS.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4304 I DATE EXISTING USTDISCOVERED: 430b I. FACILITY INFORMATION DO a 3/cam FACILITY ID N(Agency Use Only) - L BUSINES AME(Same as Facility Name or DBA-Doing Business As) 3. BUSINESS 91TE ADDRESS I°3. CTT'Y IN. S CJC S ri- II. TANK DESCRIPTION TANK IDN / 432. TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434. ❑ 1.A STAND-ALONE TANK Comple 0-p fa,each EI 2,ONE INA COMPARTMENTED UNIT wmP.mnmtln Me uric DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 037 540 III. TANK USE AND CONTENTS TANK USE * &,I.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ I..AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Inti c Uua al) ❑ 5.EMERGENCY GENERATOR FUEL IHSC§25281.5(C)I ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN EI 99.OTHER(Spedfy): 439. _-..........._- CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ It.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440. NON.PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ I I.OTHER NON-PETROLEUM(S .,i ) 44°b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT ❑ I.STEEL ❑ 3 FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(S ci ): 4444 SECONDARY CONTAINMENT ❑ I.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED M5. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): us4 OVFRFILL PREVENTION ❑ L AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE - 453. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLL WALL ❑ 2.DOUBLE WALL 0_99.OTHER 460. _ _--_-. _ SYSTEM TYPE _ ❑ L.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION- 4 SAFE SUCTION[23 CCR§263fi(ax3)1._ 458. - ...._. -'"-._ _.._ PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS � 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464% SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): PIP NGrFURBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 44N VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): q4M VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify} 4�a' 464 I. VR SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46�4b°' VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 446 j' RISER SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4Mk1 FILL COMPONENTS INSTALLED ❑ I.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP as l4ti. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ❑ 1 SINGLE WALL ❑ 2 DOUBLE-WALL, ❑ 3.NO DISPENSERS _� 9f)._NONE_ 469. _. - 469b. CONSTRUCTION MATERIAL EI I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OI HER(Specify) 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODL(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 449_ IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the haurdous substance stored and that the information provided herein is true, accurate and in full compliance with legal requirements. APPLICANT SIGNATURE DATE 470' APPLICANT NAME(print) 471' APPLICANT TITLE 472' UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org