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UNIFIED PROGRAM CONSOLIDATED FORM l0/27/J� UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections f.If.lff,IV,and IX below) 430. 3ae1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.OST REMOVAL DATE UST PERMANENTLY CLOSED: 430. DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BU INESS NAME(Same as Facility Name or DBA-Doing Business As) 3. tiyaro� Qu l n e LLB D13A a o- ; OLA BUSINESS SITE ADDRESS 103. BUS S SITE CITY F Ffn UVIA G-2 OC1 -brk II. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER t .l I433 TANK CONFIGURATION:THIS TANK IS 034. ho}� 1.A STAND-ALONE TANK Complde one page fareach 7 ^ ! .ONEINA COMPARTMENTED UNIT c Pvenmtinthewit DATE ST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS M THE UNIT 437. S�'�l 6, 8N C M. TANK USE AND CONTENTS r TANK USE ❑ is.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ 1..AVIATION FUELING 439. 6 ❑ 3.CHEMICAL PRODUCT STORAGE F 4.HAZARDOUS WASTE(mdW.Uma Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(1)] [16.OTHER GENERATOR FUEL 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ Is.REGULAR UNLEADED ❑ I..MIDGRADE UNLEADED ❑ It.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): Wa. NON-PETROLEUM: 7.USED OIL ❑ 10.ETHANOL 2 1 L OTHER NON-PETROLEUM(S eci ): 4406 (/1- IV. TANK CONSTRUCTION nr TYPE OF TANK I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN443. I v e ' PRIMARY CONTAINMENT 5L I.STEEL ❑ 3.FIBERGLASS [16.INTERNAL BLADDER 444. ❑ 7.STEEL INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): SECONDARY CONTAINMENT ❑ I.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER [1[17.JACKETED 445. El90_NONE ❑ 95.UNKNOWN X99.OTHER(Specify): NIL [//}[(L'r' 445% OVERFILL PREVENTION ❑ I.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION J.I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 99.OTHER460. SYSTEM TYPE Ip,I.PRESSURE )$2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2616(.)3)] 458. PRIMARY CONTAINMENT J.1.STEEL ❑ 4.FIBERGLASS :9 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. ❑ 90.NONE ❑ 95.UNKNOWN DI 99.OTHER(Specify): 0&A/Nj;ZAEp-E V,4j f(,r' 4641 PIPINGITURBINE CONTAINMENT SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL P&90.NONE 4Md 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): 464e1 VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4 FIBERGLASS ❑ 10.RIGID PLASTIC �90.NONE ❑ 99.OTHER(Specify): 464ng VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 44644 1. VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC90.NONE ❑ 99.OTHER(Specify): 46441 -.._._ VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL_ R 90.NONE t RISER PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC XW1.NONE ❑ 99.OTHER(Specify): 4M4. 464'. RISER SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Spwify): 469k 464kl. FILL COMPONENTS INSTALLED ❑ I.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451.1. VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ I.SINGLE WALL [12.DOUBLE WALL ❑ 3.NO DISPENSERS 90.NONE 40. - _.... .._. ... . _._-__- CONSTRUCTION MATERIAL El1.STEEL ❑ 4.FIBERGLASS Ell0.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696469. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 13 6.ISOLATION 448. IR. 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 m liance with legal requirements. APPLICANT SIGNATURE DATE 470 APPLICANT NAME(print) Q✓a Yeo 471' APPLICANT TITLE Cr6Itner 472 UPCF UST-B Rev.(12/2007)-112 www.unidws.org EtTective OI/17/08