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FIED PROGRAM CONSOLIDATED F 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 thissecfion and Sermons 1,II,III,IV,and IX below) 430 X 1.NEW PERMIT El 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL 4306 DATE UST PERMANENTLY CLOSED: 439a DATE EXISTING UST DISCOVERED: I. FACILITY INFORMATION FACILITY 11)N(Agency Use Only) - - 1 3 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) Tower#876 BUSINESS SITE ADDRESS 103 CITY 104 14000 E.H 88 ford H.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 3 Unknown X I.A STAND-ALONE TANK � � I �3�6� ❑2.ONE IN A COMPARTMENTED UNIT. Co Ine one a for each wm arvnevt iv the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 10,000 1 III.TANK USE AND CONTENTS TANK USE x la.MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL IHSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439. CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ le.MIDGRADE UNLEADED ❑1b.PREMIUM UNLEADED 440 x 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS [18.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 44oa NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 4906 I1.OTHER NON-PETROLEUM(Specify): IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL x 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT x 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 [17.STEEL+INTERNAL LWING ❑ 95.UNKNOWN [I99.OTHER (Sped ): 944. SECONDARY CONTAINMENT X 1.STEEL ❑ 3.FIBERGLASS [16.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 [190.NONE [195.UNKNOWN [199.OTHER(Specify): 4459 OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT x 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED x 2.DOUBLE-WALLED ❑99.OTHER 469 SYSTEM TYPE x L PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458 PRIMARY COF]TAA]LgN'T ❑ I.STEEL X 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL x 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify) 464c PIPINGfr R2BINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL [I 2.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT E] L STEEL x 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL x 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.0THER(Specify) 464¢ 464Fl VR PRIMARY CONTAINMENT ❑ 1.STEEL X 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4649 464 1 VR SECONDARY CONTAINMENT ❑ L STEEL X 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENC PIPING TRANSITION SUMP TYPE ❑ LS WALL x 2.DOUBLE WALL ❑ 90.NONE 469. RISER PRIMARY CONTAINMENT x L STEEL ❑ 4.PIDERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Spxify) 4691 464'1 RISER SECONDARY CONTAINMENT ❑ i.STEEL x 4.FIBERGLASS [I10.RIGID PLASTIC Ll 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED x L SPILL BUCKET x 3.STRIKER PLATEBOTTOM PROTECTOR x4.CONTAINMENT SUMP 451.-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE X 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE ®<:�.. 469. CONSTRUCTION MATERIAL ❑ 1.STEEL x 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 99.OTHER(Specify) - 469bc VIII. CORROSION PROTECTION ' STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL.ANODES) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION k; 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, amd in fWl com lienee with I al requirements. -- 470 APPLICANT SIGNA DATE 47z. 471' APPLICANT TITLE Compliance Manager APPLICANT NAME(print) Dulcinea Webb Rev.(12/2007) UPCF UST-B-1/1