Laserfiche WebLink
1 UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK lib/�7 <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One(alts per UST) <br /> TYPE OF ACTION (Check one item only. For a UST closure or removal.complete only this section and Sections I.It III,II!and LYbelow) 430 <br /> 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430. DATE EXISTING UST DISCOVERED: y" /e3 �G 430b. <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) <br /> BUSINESSlj (Same as Faeili Name or DBA-Doing Business As) 3 <br /> G QS.0 Ae0r7�� <br /> BUSLIyE'SSLSHE ADDRESS 103 CITY <br /> II. TANK DESCRIPTION <br /> TANK ID# 432. TANK MANUFACT1URER 433. TANK CONFIGURATION:THIS TANK IS 434. <br /> �_4iMK �i/N1-_ ASTAND-ALONE TANK Complcm orc page foreach <br /> C..On "nom! ❑ 2.ONE MA COMPARTMENTED UNIT comlamnmtint,un it <br /> DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 439 NUMBER OF COMPARTMENTS IN THE UNIT 437. <br /> M. TANK USE AND CONTENTS <br /> TANK USE ❑ Ia.MOTORVEHICLEFUELING ❑ Ib.MARINA FUELING ❑ 1..AVIATION FUELING 439. <br /> .9.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE ft[W.Uivi DI) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] <br /> El6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN 1399.OTHER(Specify): 439. <br /> CONTENTS PETROLEUM: ❑ 1..REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440. <br /> ❑ 3.DIESEL ❑ 5.JET FUEL M 6 AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL $9.OTHER PETROLEUM(Speufy): <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ---'---' <br /> ❑ 11.OTHER NON-PETROLEUM(Smit): 4401 <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL ft 2.DOUBLE WALL ❑ 95 UNKNOWN <br /> PRIMARY CONTAINMENT -&-1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99 OTHER(Spm*): 444. <br /> SECONDARY CONTAINMENT$I.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S ify): qq5. <br /> OVERFILL PREVENTION ❑ LAUDIBLE&VISUAL ALARMS 02.HALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION E UIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ,pI.SINGLE WALL ❑ 2.DOUBLE WALL [199.OTHER 460, <br /> SYSTEM TYPE <br /> y�- I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4 SAFE SUCTION[23 CCR§2636(.7(3)] 458. <br /> PRIMARY CONTAINMENT -�;1.STEEL ❑ 4.FIBERGLASS $.^8.FLEXIBLE U 10.RIGID PLASTIC 464. <br /> O 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ I0.tRIGID PLASTIC 4646. <br /> ❑ 90.NONE ❑ 95.UNKNOWN AR'99.OTHER(Specify): ryy§t: v y(t­ 464c <br /> AINMEN <br /> PIPING/fURBINE CONT <br /> T SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 464a <br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC Q 90.NONE ❑ 99.OTHER(Specify): g64e1 <br /> VENT SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): <br /> 464G. <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ l0.RIGID PLASTIC ID 90.NONE ❑ 99.OTHER(Specify): �' <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLAS$ ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 4641 <br /> 444 h <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑2.DOUBLE WALL IN 90.NONE <br /> RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 4641 <br /> 464'1. <br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC IS 90.NONE D 99.OTHER(Specify): 4 1t <br /> FILL COMPONENTS INSTALLED 464k1. <br /> ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLA PROTECTOR ❑ 4.CONTAINMENT SUMP 451. <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL [13.NO DISPENSERS 90.NONE 469. <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4691. <br /> 469c <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT St 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 inform don provided herein is true, <br /> accurate and in full compliance with le al requirements. <br /> APPLICANT SIGNATURE DATE 470. <br /> APPLICANT NAME(print) 471. APPLICANT TITLE 472. <br /> UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org <br />