Laserfiche WebLink
+ WFIED PROGRAM CONSOLIDATED FOIWN <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) <br /> TYPE OF ACTION (Check one item only. Fora UST closure or removal,complete only this section and Sections I,II,III,/V,and IX below) <br /> a3o. <br /> ❑ 1.NEW PERMIT 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSUREDATE EXISTING UST 8.UST REMOVAL 4306. <br /> DATE UST PERMANENTLY CLOSED: <br /> I. FACILITY INFORMATION <br /> 1. <br /> FACILITY ID#(Agency Use Only) <br /> 3. <br /> BUSINESS NAME(Sa as Faci/iry Name r A�Doiyd Busi sAs) 'G 0 <br /> BUS SS AD RESS 103. (IT loo. <br /> CITY Stec K <br /> / <br /> II. TANK DESCRIPTION <br /> TANK ID# 432. TANKMANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. <br /> /a /n� I.A STAND-ALONE TANK Complete one page for each <br /> !r/ f ❑ <br /> 2.ONE M A COMPARTMENTED UNIT compamment in the fm e <br /> DATE UUSSTT S ST INSTALL Le43s. TANK CA IN GALLONS 436- NUMBER OFF CCOOMPARTMENTS IN THE UNIT 437. <br /> III. TANK USE AND CONTENTS <br /> TANK USE J..MOTOR VEHICLE FUELING [I16.MARINA FUELING ❑ Ic.AVIATION FUELING 439, <br /> 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c] <br /> [:16.OTHER GENERATOR FUEL [195.UNKNOWN _❑ 99.OTHER(Specify): <br /> 439. <br /> CONTENTS PETROLEUM: *W a.REGULAR UNLEADED ❑ ]c.MIDGRADE UNLEADED 0 lb.PREMIUM UNLEADED 440' <br /> LJ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ S.PETROLEUM BLEND FUEL 9.OTHER PETROLEUM(Specify)_ <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 440b. <br /> ❑ 11.OTHER NON-PETROLEUM Specify): <br /> IV. TANK CONSTRUCTION <br /> _TYPE OF TANK (]--1.SINGLE WALL .DOUBLE WALL ❑ 95 UNKNOWN a41. <br /> - _ __-____ 494. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER <br /> ❑-7.STEEL+INTERNAL LINING __________095_UNKN0WN 099_OTHER(Spectfy): 44x. <br /> SECONDARY CONTAINMENT ❑ 1.STEEL W.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445' <br /> 445e. <br /> [190.NONE 95.UNKNOWN ❑99.OTFIER(Specify): __ <br /> 452. <br /> OVERFILL PREVENTION AUDIBLE&VISUAL ALARMS 13��.BALL FLOAT ❑ 3.FH.L TUBE SHUT-OFF VALVE <br /> �.TANK MEETS RE UIREMENTS FOA EXEMPTION FROM OVERFILL PREVENTION E UIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> 460. <br /> PIPING CONSTRUCTION ._- [1 1.SINGLE WALL -.W2.DOUBLE WALL 0 99.9THER <br /> 1.PRESSURE 0 2.GRAVITY ____ 3 CONVENTIONAL SUCTION ❑_4_SAFE SUCTION[23 CCR g2636(aH3)I <br /> 458. <br /> � <br /> 464. <br /> PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FBERGLASS �S.FLEXIBLE ❑ 10.RIGIDPLASTIC 4W_ -___ 90.NONE 0_95_UNKNOWN____-_0 999.OTHER(�dy):_ 4646. <br /> SECONDARY CONTAINMENT [31.STEEL ❑ 4.FIBERGLASS .FLEXIBLE ❑ 10.RIGH)PLASTIC 04c <br /> _ ❑ 90.NONE -0 95.UNKNOWN ❑_99_._OTHER(Specif-y)__ <br /> PIPING/fURBINE CONTAINMENT SUMP TYPE 15r4.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d. <br /> VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> 46x. <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL �4_FIBERGLASS ❑ 10.RIGID PLASTIC [190.NONE [399.OTHER(Specify)_ 464e1. <br /> 464f. <br /> VENT SECONDARY CONTAINMENT ❑ I.STEEL M4.FIBERGLASS ❑ 10 RIGIDPLASTIC' ❑ 90.NONE [199.OTHER(Specify): 4640, <br /> .- 4648. <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL tjCA.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): q6a 1. <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL T�4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE_❑ 99.OTHER(Specify): 464h1. <br /> _ ____- _-__- 464,. <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL [12.DOUBLE WALL90.NONE _ <br /> 464j. <br /> RISER PRIMARY CONTAINMENT ❑ L STEEL 94.FIBERGLASS [_110.RIGIDPLASTIC [390.NONE [j99.OTHER(Specify): 464'1. <br /> 464k. <br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC �M.NONE ❑ 99.OTHER(Specify): 464k1. <br /> FILL COMPONENTS INSTALLED I.SPILL BUCKET R3.STRIKER PLATEMOTTOM PROTECTOR 3r.CONTAINMENT SUMP 451.,. <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE 1.SINGLE WALL ______,-....__0,,2_DOUBLE WALL „I NO DISPENSERS_.0 90.NONE 469a. <br /> ___.....-.-_ ____...-..... __-.____.. ..... .._..._-_ 4696. <br /> CONSTRUCTION MATERIAL ❑ 1 STEEL ❑ 4.FIBERGLASS ]0.RIGID PLASTIC ❑ 99.OTHER(Specify) 469.. <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, <br /> accurate,an ' 'ante wi a em S. <br /> DATE 0/ / 2azo. <br /> APPLICANT SIGNATURE f�77 O9, <br /> APPLICANT NAME(print) 1 Vj,I.1 IJ a71' APPLICANT TITLE <br /> UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org ✓G•,e (/ <br />