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'61q1j L.5 -rA p 5 ;2a Bp--aj Lm-it -. UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK 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 I,U,UI,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: 430' DATE EXISTING UST DISCOVERED: 4106 L FACILITY INFORMATION D.2419 FACILITY ID#(Agency Use 0*) Lt - BUS NA (Sam�ILITY N or DBA-Doing Business As) 3 S,l1, BUSINESS STI'E ADRESS Ito C IN H.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK Is 436 � �'l . ❑7 I.A STAND-ALONE TANK �y7✓S�yIc1�1�� -"'�hS W2.ONE INACOe P ENTED UN R. Com eta ove for earhw w,,�tin the utu[ DATE UST SYSTEM INSTALLED 435 TANK C AAC T IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 M.TANK USE AND CONTENTS TANK USE --i;L In.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Iovlmks Used a) ❑ 5.EMERGENCY GENERATOR FUEL LII.SC 1u28Ls(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 43% CONTENTS PETROLEUM: ❑ Ia REGULAR UNLEADED 1c.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 4W ❑ 3.DNSEL 5.)ET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): "Is NON-PETROLEUM:❑ 7.USED OI. ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM $ e6 : 44ab IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOIJBLP WALL ❑ 95.UNKNOWN a3 PRIMARY CONTAINMENT ❑ I.STEEL *3.FIBERGLASS ❑ 6.TNTERNAL BLADDER 4N ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (specify): 444a SECONDARY CONTAINMENT ❑ 1.STINT. .FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER S 445• OVERFILL PREVENTION -S.L 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 451 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION Ell-.SINGLE-WALLED 2.DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE .PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR 12636(s)(3)1 458 PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Spedfy): 46G SECONDARY CONTAINMENT ❑ 1.STEEL4.FIBERGLASS [18.FLEXIBLE ❑ 10.RIGID PLASTIC 46M ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Spcify): 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 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 466 4661 VENT SECONDARY CONTAINMENT I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC El 90.NONE ❑ 99.OTHER(Specify) 464E d64fl VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 4641 46491 VR SECONDARY CONTAINMENT ❑ 1.SIIiEI. N,4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 964h1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL 0 90.NONE 46G. RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 4641 RISER SECONDARY CONTAINMENT 1.STEEL 1S1,4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ W.NONE ❑ 99.OTHER(Specify) 464k 46411 FILL COMPONENTS INSTALLED I.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 451st VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL r9,2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE a69e CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHERS ) 4696c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.PAPRESSED CURRENT 6.ISOLATION 441. 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 470. APPLICANT NAME(print) - APPLICANT TITLE 4n. UPCF UST-B-12 Rev.(122007)