BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

UNHUD PROGRAM CONSOLIDATED FORM � ) f UNDERGROUNDSTORAGETANK / OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYKOF ACTTON (Check one item only. For a USTclosure or removal,complete only this section and Sections 1,I!,IQ IV,,and Mbelow) 430. 1.E NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430. DATE EXISTING UST DISCOVERED: 4304 I. FACILITY INFORMATION ANEEM FACILITY ID#(Agency Use Only) _ c) -1; BUSINESS NAME(Same Facility Name r BA-Doing us' ss As) _..e. BUSINESS SITE ADDRESS 1 103. CITY k t04. J]fnJ II. TANK DESCRIPTION TANK ID# ` O ZT 432. TAtNK MANUFACTURER 433. TAI CONFIGURATION:THIS TANK IS 434. Q1 Qf-oCff .ASIAN)-ALONE TANK Cmvpltto Phe forexA DATE UST SYSTEM INSTALLED 4Js. TANK APACITYINGAL NS q D 2.ONEINA COMPARTMENTEDUNIT -paoacainm aoit NUMBER OF COMPARTMENTS IN THE UNIT 437. l 5 Sv III. TAU-IUSE AND CONTENTS TAN&USE ❑ Ia.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ 3.CHEMICAL PRODUCTSTORAGE ❑ Ic.MERGONFUELING 419. ❑ 4.HAZARDOUS WASTE(Ivdudes Used Oi0 ❑-155 EMERGENCY GENERATOR FUEL[HSC§25281.5(.)] ❑ 6.OTHER GENERATOR FUEL ❑ 9S.UNKNOWN 1y�v9.OTHER(Specify): i 4J9a CONTENTS PETROLEUM: ❑ ]..REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440. NON-PETROLEUM: 7. SED OIL -"---'_--'-- ❑ 10._ET WA 1.OTHER NON-PETROLEUM S iMMMM (Q,OLµJ C�LC4dYl t 4404 Tf CO STR CTIO s 1YPE OF TANK 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER -444. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify)• 444. SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE �95.UNKNOWN _ ❑99.OTHER(Specify): 445. OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS RE UIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTIONE UIPMENT P ODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION .SINGLE WALL ❑ 2.DOUBLE WALL ❑ 99.OTHER 460, SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION_ ❑ 4.SAFE SUCTION[23 CCR§2636(.)3)] 458. PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. SECONDARY CONTA]Nb]ENT' ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 4644 ❑ 90.NONE ❑ 95.UNKNOWN _ 99.OTHER(Specify): 464. PIPING/TIJRBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644. SENT OR RECOVERY Wit) AND RISER/FILL_PIPE PIPING CONSTRLL(�DI VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHERec'S ( P �)' 469e1. VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464H VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4 d64�a VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464ht VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464i RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464J. 464'l. RISER SECONDARY CONTAINMENT El1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC El90.NONE ❑ 99.OTHER(Specify): 4"k 464k1. FILL(AIMPONflN7S INSTA-LLED ❑ L SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT BUMP Slaa VII UNDERIDISPENSERfONTAINMENT(UDG)j CONST RUCTION T YPE ❑ 1 SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90 NONE 469. CONST RUCTION MATERIAL ❑ LSTEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) "gc VIII. CO _O IO_N PROTECTION STEEL COMPONEN"I PROTECTION ❑ 2.SACRIITCI4LANODE(S) Ll 4.IMPRESSED CURRENT ❑ 6.ISOLATION 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 ar in full co: ce with legal requirements. APPLICANT SIGNATUREDATE ILc>10 470. APPLICANT NAME(print) /N a71. APPLICANT TITLEP0&/[C� ^ -, 4n. UPCF UST-B Rev.(1212007)-1/2 www.uuidoes.org e4C iY�"'