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• • �� UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One fa,m per UST) TYPE OF ACTION (Check one item only. For a UST clostrre or removal,complete only this section and Sections 1,11.111,IV,and IX below) 430. 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ONSITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430% DATE EXISTING UST DISCOVERED: IV--/5r-/4P 43on I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESSlj E(Same as Facilq Name or DBA-Doing Business As) 3 G 4SF� �Q.1)Yi7�Pi BUSIyESS SITE ADDRESS 103. Cpy las_ b�y. l a/►�...� as -fb �-o._. II. TANK DESCRIPTION TANKID# / q�p�/ 452. TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 ( V UO b /+_ �11„^��/til__ �`I.A STAND-ALONE TANK COn Iftomp Forsch G_O.+ "no..� ❑ 2.ONE M A COMPARTMENTED UNIT 1.ft is DAIL UST SIbILM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437. M. TANK USE AND CONTENTS TANK USE ❑ Is.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ I..AVIATION FUELING 439. -Q9.CHEMICAL PRODUCT STORAGE ❑4.HAZARDOUS WASTE(b,]Wes Uses Off) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(01 ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ Is REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS Q4filr 4ai/ ❑ 8.PETROLEUM BLEND FUEL %9.OTHER PETROLEUM(Specify): 1$. -7'5W-9,0 JJ 440e NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL -"'----- ❑ 11.OTHER NON-PETROLEUMS ): 4406. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ft2.DOUBLE WALL ❑ 95.UNKNOWN_ qq3, PRIMARY CONTAINMENT -Ik1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444, SECONDARY CONTAINMENT-lit].STEEL [3 3.FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 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 E42UIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 99.OTHER 460. SYSTEM TYPE -49r 1.PRESSURE _ ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(.x3) 4$8. PRIMARY CONTAINMENT -,J.STEEL ❑ 4.FIBERGLASS WJ FLEXIBLE ❑ 10.RIGID PLASTIC 464. 1190.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. SECONDARY CONTAINMENT ❑ 1.STEEL ❑4.FIBERGLAS$ ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. ❑ 90.NONE ❑ 95.UNKNOWN AN-".OTHER(Spedfy) PIPING,TURBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 4646 VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 4 44 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC Q 90.NONE ❑ 99.OTHER(Specify): a640 VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC m 90.NONE ❑ 99.0THER(Specify): 464 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑4.FIBERGLASS 0 10.RIGID PLASTIC SI 90.NONE ❑ 99.OTHER(Specify): 469A VENT PIPING TRANSITION SUMP TYPE 111.SINGLE WALL ❑ 2.DOUBLE WALL L9 464h1. 90.NONE RISER PRIMARY CONTAINMENT ❑ L STEEL ❑4.FIBERGLASS Q 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 4693 464"1. RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ I0.RIGID PLASTIC LS90.NONE ❑ 99.OTHER(Specify): 464t1 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451 c VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS 90.NONE 469• CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 44 VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST System is compatible with the hazardous substance stored sad that the Information provided hereto is true, accurate and in full com haste with legal requirements. APPLICANT SIGNATURE DATE 470. APPLICANT NAME(print) 901" APPLICANT TITLE 472. UPCF UST-B Rev.(12/2007)-112 www.unhlocs.org