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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION tone fom perm) <br /> VOF ACTION (Check one item only For a UST closure or removal,complete only this section and Sections L 11,III, <br /> 1. ElIV,NEW PERMIT 3.RENEWAL PERMIT El 5.CHANGE OF a39. <br /> and IX below)INFORMATION <br /> ❑ 7.UST <br /> El 6.TEMPORARY UST CLOSURE PERMANENT CLOSURE ON STTE 8.UST REMOVAL <br /> DATC UST PERMANENTLY CLOSED: 4w. DATE EXISTING UST DISCOVERED: 43gh <br /> - <br /> (Agency Use Duly) <br /> BUSINESS NAME(S¢me as ¢eiliry Name o A-Doing Bus' ess A t � 2 <br /> IJ 3. p <br /> BUSINESS SITE ADDRE ; 103. / <br /> N 1aln (Lr� • CITY <br /> 'Z <br /> DE @RIP1�I0 <br /> TANK ID q 5t 6 19 432 ANK MANUFA T�p�II[' ...rte <br /> y- CTURER 433. LK CONFIGURAIION:THIS TANK IS 434. <br /> 1 1.ASTAND-ALONE TANK C-Pleec-pagefaceeeh <br /> DATE UST SYSTEM STALLED 43s. TANK CAPACITY IN GALLONS 436 ❑ 2.ONE INA COMPARTMENTED UNIT ®iparvnmt iv theimit <br /> p� v cJ NUMBER OP COMPARTMENTS IN THE UNIT 437, <br /> l ti L✓ <br /> M. TANK USE AND CONTENTS <br /> TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ le.AVIATION FUELING 439. <br /> _ ❑ 6.OTHER GENERATOR FUEL ❑ 4.HAZARDOUS WASTE Used Oil) -❑-`55 EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] <br /> CONTENTS PETROLEUM: ❑ 95 UNKNOWN __ LL/Y9.OTHER(Specify): 11 439. <br /> ❑ 3. REGULAR UNLEADED ❑ la MIDGRADE UNLEADED ❑ 1b.PREMRIM UNLEADED 440, <br /> ❑ 3.DIESEL ❑ SUJET FUEL ❑ 6.AVIATION GAS <br /> -_....__ ❑ B-PETROLEUM BLEND FUEL 9.OTHER PETROLEUM ISpecity):f.'TF 4g0a <br /> NON-PETROLEUM:-[] 7.USED OIL ❑ !0.ETHANOL -----................._ <br /> ❑ <br /> 11.OTHER NON-PETROLEUM(Specify): 440b. <br /> -_ <br /> TYPE of TANK - .DTAN K CONSTRUCTION <br /> I.SINGLE WALL TAALL ❑ 95.UNKNOWN <br /> 1REIIAR1 UUNI&INIKEN I MIT.STEEL ' • 443 <br /> ❑ 3.FffiERGLASS ❑ 6.INFERNAL BLADDER - - - --_ <br /> SECONDARY CONTAINMENT [17.STEEL+INTERNAL LINING ❑ 95 UNKNOWN 11 99.OTHER(Specify): 4qq. 444. <br /> .STEEL __ff 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER [f7.JACKS-MD 445. <br /> _ __.. 90.NONE 3 995.UNKNOWN ��❑99.OTHER(g ty�: 445 <br /> OVERFILL PREVENTION ❑ 7.pUDIBLE&VISU.4LALARMS [�'L.HALL FLOAT ❑ 3.FH.L TUBE SHUT-OFF VALVE <br /> ❑ 4.TANK MEETS RE UIREMENTS FOR EXEMPTION FROM OVERFILL PREVENOONE pUIPMENT <br /> . _ V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION_ SINGLE WALL. ❑ o DOf BLEIVALL ❑ 99.OTHER__ <br /> SYSTEM TYPE__ - - - ...-..--- _ __ _ 460. <br /> '. - <br /> I:PRESSURE 0 2.GRAVITY El 3_CONVENTIONAL SUCTION 0-4.SAFE SUCTION 123 CCR§]636(.X3)] 458. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑-8 - <br /> 0❑ 90.NONE ❑ 95.UNKNOWN ❑ 10.RIGID PLASTIC 464. <br /> SECONDARY CONTA]NMEN'T I.STEEL ❑ 99 OTHER(Specify)• 464g <br /> ❑ ❑ 4.FffiERCLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4Mh <br /> ❑ 90.NONE ❑ 95 UNKNOWN 99.OTHER(Specify); 464. <br /> PIPINGlCURBTNE CONTAINMENT SUMP TYPE ❑ 1 SINGLE WALL ❑ 2.DOUBLE WALL <br /> - ': �- - ❑ 90 NONE 46ad <br /> VL' VENT, VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRU__CTION <br /> VENT PRIMARY CONTAINMENT [s�l.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTTC ❑ 90.NONE <br /> VENT SECONDARY CONTAINMENT -y1.S-TEEi. ❑ 99.OTHER(Specify): 464cl <br /> M ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONfi ❑ 99.OTHER(Specify): <br /> VRPRIMARY CONTAINMENT 4648. <br /> ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ I0.RIGID PLASTIC ❑ 90_NONH ��- <br /> ❑ 99.OTHER(Specify): <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS 4fi9 N <br /> ❑ 10.RIGID ALL ❑ 90.NONE ❑ 99.OTHER(Specify): 46644h� <br /> VENT PIPING TRANSITION SUMP TYPE ❑ i.SINGLE wqu ❑ z.DOUBLE WA LL ❑ go.NoxE <br /> RISER PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): <br /> RISER SECONDARY CONTAINMENT -' ---'--' - --- 464'x. <br /> _❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): a k <br /> --- - - 464.1. <br /> FILL COMPONENTS INSTALLED ❑ 1 SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR- 451 a-c. <br /> -„ ❑ 4.CONI'AIbtENT SUMP <br /> VII. UNDER DISPENSER_CONTAINMENT(UDC) <br /> _CONS T RUCIIOV I}PB _ ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL <br /> -- ❑ 3 NO DISPF\SEAS _❑ 90 NONE. VC9n <br /> CONSTRUCTION MATTR[AI. -'IC - _ <br /> ❑ 1 STEEL ❑ 4 FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Sp eciC) 469b. <br /> 469:. <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2-SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. <br /> LY. APPLIC_ ANT SIGNATURE <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, <br /> accurate, d in full c0 PlAftwith legal requirements. <br /> APPLICANT SIGNATURE - DATE 470. <br /> Zo/o <br /> APPLICANT NAME(print) 421' APPLIC TITLE <br /> "� I�LGL� /f'v✓ �!� <br /> UPCF UST-131 Rev.(17J2007).1/2 www.unidocs.org <br />