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MOP, xy l UNIFIED PROGRAM CONSOLIDATED FORM J JJJ UNDERGROUND STORAGE TANK PERATING PER OMIT APPLICATION-TANK INFORMATION(One form per(UST) / T❑YP1.E OFA CTION N (Chock one item only. Foran UST permanent closure or removal,complete only this section end Sections 1,II,III,N,and IX below) 430 EW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 0 7.UST PERMANENT CLOSURE ON SITE Q 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: - DATE EXISTING UST DISCOVERED: 4306 FACILITY ID N I. FACIIITY INFORMATION (Agency Use OMyJ - _ 1 BUIkTSS NAME(S{u{ran�e as FACILITY NAME or DBA-Doing Business AS) �n§ � SlI �/! 4 BUSINESS SRE ADDRESS 103 Cf1Y .✓ II.TANK DE N TANK ID ff 432 TANK MANUFACTURER 433 T ,V 1. CONFIGURATION: THIS TANK IS / 434,V1.A STAND-ALONE TANK 2.ONE IN A COMPARTMENTED LTM. DATE UST SYSTEM INST LED 43s4r^ �� era.a Neuvit. TANK CAPgCIFY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 Soo M.TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 49 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(jwJ U4e3 Olp ❑ 5.EMERGENCY GENERATOR FUEL[NSC g252at 5(c)j 1 1 ❑ 6.OTHER GENERATOR FUEL 0 95.UNKNOWN ❑ 99.OTHER (Specify): 43 CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL 9.OTHER PETROLEUM S i : 30 l�-p•Tq-- O r 4a0a ,I�/. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL V I� Ej I I.OTHER NON-PETROLEUMS i : I V IV. TANK CONSTRUCTION `lI TYPE OF TANK 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN PRIMARY CONTAINMENT 1.STEEL ❑ 3.FIBERGLASS 40 ❑ 6.INTERNAL BLADDER 443 `V 7.STEEL+INTERNAL LINING 95.UNKNOWN ❑ 99.OTHER (S i SECONDARY CONTAINMENT 1.STEEL ❑3.F®ERGLASS ❑ 6.E%TERIOR MEMBRANE LINER ❑ T.3ACKEYED 90.NONE ❑ 95.UNKNOWN ❑99.OTHER5 ): Cd..q Sa OVERFILL PREVENTION LAUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILLNBESHUT-OFF VALVE 452. 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION LSINGLE-WALLED IJ2.DOUBLE-WALLED 1199.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(¢X3) 458 PRIMARY COMAfNhtEM I.STEEL LJ 4.FIBERGLASS S.FLEXIBLE ❑ 10.RIGID PLASTIC 469 ❑ 9NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Smcify): 960a SECONDARY CONTAINMENT 130.1.STEEL 4.FIBERGLASS 8.FLE%THEE ❑ I0 RIGIDPLASTIC 4696 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER PIPMCrt[I(BINE COMAINMEMSUMPTYPE LJ1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VL VENT,VAPORRECOVERY(VR)AND RISER/FILL,PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT U I.STEEL U 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 46ae VENT SECONDARY CONTAINMENT L STEEL 9.FIBERGLASS 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464f VR PRIMARY CONTAINMENT LSTEEL 4.FIBERGLASS 1 -MUIDPLASTIC M 90.NONE 99.OTHER(Specify) 4648 VR SECONDARY CONTAINMENT I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 46419 VENT PIPING TRANSITION SUMP TYPE LSINGLE WALL 2.DOUBLE WALL 90.NONE 46461 RISER PRIMARY CONTAINMENT i.STEEL 4.F®ERGLASS 10.RIGID PLASTIC W.NONE 99.OTHER(Specify) 464j RISER SECONDARY CONTAINMENT L STEEL 4.FIBERGLASS 10.RIGID PLASTIC - 90.NONE 99.OTHER(Specfy) 464k FILL COMPONENTS INSTALLED I,SPILL BUCKE7 3.STRIXERPLATFIBOTTOM PROTECTOR 4.CONTAINMENT SUMP 4�..4 VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.I WALL ❑ 3,NO DISPENSERS 90,NONE 469¢ CONSTRUCTION MATERIAL ❑ L STEEL ff 4.FIBERGLASS 10.KIGID PLASTIC ❑ 99.GTHER(S ify) g6gbc VIII. CORROSION PROTECTION STEEL COMPONEPROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the Information Provided herein is true,am ate, and to full cora Lance with 1 al r ulrements. APPLICANT SIGNATURE DATE 430. APPLICANT NAME(print) 421' APPLICANT TITLE 472. UPCF UST-8-1/2 Rev.(12/200-))