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• ! To <br /> �1` <br /> y UNIFIED PROGRAM CONSOLIDATED FORM E:430. <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (OT) <br /> TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,//,//!.fP,and/X below) <br /> I.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 0 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430. 1 DATE EXISTING UST DISCOVERED: y' �s -� 43& <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) _ _1 jljoje42�[ 1 <br /> BUSINESS (Some as Fac Jli Nome or DBA-Doing Business As) 3. <br /> v 49.0 AF. V.iei <br /> BUSII�66 / DRESS D4rs 103. CITY 1w. <br /> -& <br /> II. TANK DESCRIPTION <br /> TANK IIDD,,,# 432, TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK 1S 434. <br /> /�� /+_ ^u„h��,�'/N1- 'a`[.A STANRALONE TANK Complereo�c form <br /> r f_Or. 'rlw.�! 2.ONEINA COMPARTMENTED UNIT wml wtinmewiL <br /> DATE UST SYSTEM INSTALLED 433 1 TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. <br /> M. TANK USE AND CONTENTS <br /> TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING <br /> - ❑ AVIATION FUELING 439. <br /> -S.CHEMICAL PRODUCT STORAGE �l4.HAZARDOUS WASTE(IndWmUsal nip ❑ 5.S.EMERGENCY GENERATOR <br /> ATOR FUEL[HSC§25281,5(c)] <br /> 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN _ ❑ 99.OTHER(Specify): 439. <br /> CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440. <br /> Q 3.DIESEL rT 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL 3.OTHER PETROLEUM(Specify): sans <br /> NON-FETROLEUMA 7.USED OIL L3 10.ETHANOL -- -"'--- <br /> Q 11.OTHER NON-PETROLEUM(Specify): 440b. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK Q L SINGLE WALL A%2.DOUBLE WALL <br /> ❑ 6.INFERNAL <br /> BL-ADDER 443. <br /> PRIMARY CONTAINMENT jkI.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL 4a<. <br /> ❑ 7.STEEL+INTERNAL LINING Q 95.UNKNOWN Q 99.OTHER(Specify) 444. <br /> SECONDARY CONTAINMENT Aii1.STEEL [13.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER <br /> Q 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify)' Q 7.JACKETED 445. 495. <br /> OVERFILL PREVENTION ❑ I.AUDIBLE B VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 99.OTHER 460. <br /> SYSTEM TYPE $�eI1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION [14.SAFE SUCTION[23CCR§2636(.x3)] 459. <br /> PRIMARY CONTAINMENT -W.STEEL ❑ 4.FIBERGLASS a"S.FLEXIBLE ❑ 10.RIGID PLASTIC 464. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. <br /> SECONDARY CONTAINMENT Q I.STEEL Q 4.FIBERGLASS ❑ 8.FLEXIBLE <br /> ❑ 90.NONE ❑ 95.UNKNOWN �Li.n ❑ 10./R�IGID PLASTIC 4646. <br /> �'2. OTHER(Specify): T1&90.N v w(t- 464c <br /> PIPINGR'URBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 464d. <br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL Q 4.FIBERGLASS ❑ 10.RIGID PLASTIC [sl 90.NONE Q 99.OTHER(Specify): 464e1 <br /> VENT SECONDARY CONTAINMENT Q 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC Ig 90.NONE Q 99.OTHER(Specify): 464 <br /> a64n. <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC N 90.NONE ❑ 99.OTHER(Specify): q�B <br /> VR SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 10 90.NONE Q 99.OTHER(Specify): g4tAh <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL L9 90.NONE <br /> ilw- <br /> RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE Q 99.OTHER(Specify): <br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC [!1 90.NONE ❑ 99.OTHER(Specify): 46/t <br /> FILL COMPONENTS INSTALLED ❑ I.SPILL BUCKET Ll3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451. <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE Q L SINGLE WALL ❑ 2.DOUBLE WALL Q 3.NO DISPENSERS Ck 90.NONE 469. <br /> CONSTRUCTION MATERIAL ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC Q 99.OTHER(Specify) <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION Q 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT Q 6.ISOLATION 449. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: 1 certify that this UST system is compatible with the hanrdous substance stared and that the information provided herein is true, <br /> accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 470. <br /> APPLICANT NAME(print) 47). APPLICANT TITLE 4n. <br /> UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org <br />