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• Z r, UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK 0 OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per usT) E OF ACTION (Check one item only. Fora UST closure or removal,complete only this section and Sections I,R,Ill,IV,and IX below) 430. 1 NEW PERMIT ❑ 3•RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON STTE ❑ 8.UST REMOVAL DATE USE PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID 7(Agency Use Only) BUSINESS NAME(Samea Facility Name rDBA-Doi'rt¢BnslnasAs) r f� •iL G BUSINESS SITE ADD1 ISS � '2A 103. Cppy 104 J K `_��"Oc��z� II. TANK DESCRIPTION TANK ID# T l�45,16?��32. TANK MANUFACTURE 433. TANK CONFIGURATION:THIS TANK IS 434. -, UrNVVf �T� �aech v� �f ASTAND-gLONE TANK Ideane RATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS q36, ❑ 2.ONE IN A COMPARTMENTED UNIT camnamneot�the unit c� INSTALLED OF COMPARTMENTS IN THE UNIT 437. OO& FUSE AND CONTENTS TANK USE ❑ 1..MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ IQ AVIATION FULLMG 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Incmda Used Oi0 ❑ 5MERGENCY GENERATOR FUEL IHSC§25281.5 6.OTHER GENERATOR FUEL 095.UNKNOWN meQ9.OTHER(Spedfy): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ 1c.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 4q0. ❑ 3.DIBSEL ❑ 5 FUEL q 6,AVIATION GAS --.. ❑ 8.PETROLEUMBLENDIKL L 9.OTHER PETROLEUM(Specify): nJcp-t OI ( 440. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL --'----------- ❑ IL OTHER NON-PE TROLEUM(Specify): 440b. IV. TANK CONSTRUCTION TYPE OF TANK 1.SINGLE WALL 2.DOUBLE WALL ❑95.UNKNOWN ., q43. PRIMARY CONTAINb�IT 1.STEEL INTERNAL LADDER - ❑ 3.FIBERGLASS ❑ 6.MTEANAL BLADDER --- qqq:- ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN 1199.OTHER(Specify); 444a SECONDARY CONTAINMENT-- STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.]ACKETED 4455. ❑ 90.NONE ❑ 95.UNKNOWN _ ❑99.OTHER(Specify)' 445 OVERFILL PREVENTION ❑ 1.AUDIHLE&VISUAL ALARMS Ly 2. ALL FLOAT 03.FILL TUBE SHUT-OFF VALVE 453. ❑ 4.TAT K MEETS REQUIREMEMS FOR EXEMPTION FROM OVERFILL PREVENTION E UIBMENT . PRODUCT/WASTE PIPING CONSTRUCTIC L ,, PIPING CONSTRUCTION .SINGLE WALL- (] 2 DOL WALL ❑ 99.OTHER .. SYSTEM TYPE -----"----- --- __ _-..._ LSTESSURE Ej 2 GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4 SAFE SUCTIONp3CCR§3636OfdA 458. PRIMARY CONTAINbiIINT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ MOTHER(Specify): 464s SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4•FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464h -- 0 90.NONE ❑ 95.UNKNOWN ❑ 99 OTHER(Specify): q PeINGlI'[JRBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI. VENT, VAPOR RECOVERY ` - (VR) AND RISER/FILL P_IPE PIPING CON_STRUCTION VENT PRIMARY CONTAINMENT I STEEL .. - ❑ 4.FIBERGLASS ❑ I0.RIGID PLASTIC ❑ 90.NONE (Specify): 4464M� ❑ 99.OTHER VENT SECONDARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99 OTHER(Specify)• 4 ...-_... 469fl. VR PRIMARY CONTAINMENT ❑ I-STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Spe©fy): 4 - VR SECONDARY CONTAINMENT464 t. ❑ 1.STEEL ❑ 4.FBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): m 464m VENT PIPING TRANSITION SUMP TYPE . ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE � RISER PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4�)• RISER SECONDARY CONTAINMENT ----" -"- ----- 464'1. �- - -❑ L STEEL ❑ 4.FIBERGLASS ❑ ]0.RIGID PLASTIC ❑ 90.NONH ❑ 99.OTHER(Specify): 4 �` FII.L COMPONENT$INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAMMENT SUMP 456a-a PrnVII 1UNDERtDISPENSER CONTAINMENT([JDC) TION TYPE ❑ 1.SINGLE WALL 10.RIGID PLASTIC 3 NO DISPENSFRS ❑ 90 SONE 469a CONSTRUCTION ❑ NSTRUC T1AfERIAL _ ❑ 2.DOUILE WALL_ - - _ 1.STEEL ❑ q FIBERGLASS EI C ❑ 99.OTHER(Spcmfy) 4696 VIII. CORROSION PROTECTION 462, STEEL COMPONENT PROTECTION ❑ A SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 449. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with Me hazardous substance stored and that the information provided herein is true, accura in fun c nce with legal requirements. APPLICANT SIGNATURE DATE 470, APPLICANT NAME(print) APPLIC TITL C-!_n�l _ / �N 472. UPCF UST-B Rev.(12/200.1)-1/2 /�www.uuidocs.org eG