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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,IT,III,TV,and IX below) 430 ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE RUSTING UST DISCOVERED: 4306 I. FACILITY INFO TION FACILITY ID#(Agency Use Only) _ e A 101 BUSINES NAME a as FACILITY NAM or DBA-Doing Business As) C/ "y P P �- B S ESS LTE S 1,-761 1 103 CITY II.TANK DESCRI . ION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS "4 ❑1.A STAND-ALONE TANK Y-e y • 1®2.ONE IN A COMPARTMENTEDul iOAOUIN COUNTY t tete one page for each com artment in the i DA STWil YSTEM NS LED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN 437 r 71st/ HEALTH DEPARTMENT III.'TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN 99.OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED Ellc.MIDGRADE UNLEADEDlb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTR TION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.INTE AL BLADDER 444 ❑ 7.STEEL+INTER AL LINING ❑ 95.UN OWN [199.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS [016.EXT OR MEMBRANE LINER ❑ 7.JACKETED 445 90.NONE 95.UNKNOWN 099.0 (Specify): 445a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ; ❑ 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FRCMOVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING, ONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED 2.DOUBLE-WALLED ❑4.OTHER 460 SYSTEM TYPE I.PRESSURE ❑ 2.GRAVITY ❑ 3.CON NTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR g2636(a)(3)] 458 PRIMARY CONTAINMENT 1.STEEL X 4.FIBERGLASS ❑ 8.FLEMPLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTH�R(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEX LE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTH R(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/PILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIG D PLASTIC ❑ 90.NONE [__199.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS El 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4646 464 l VR SECONDARY CONTAINMENT ❑ 1.STEEL U 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 0 2.DO LE WALL ❑ 90.NONE 464i, RISER PRIMARY CONTAINMENT I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE El99.OTHER(Specify) 4641 464j I RISER SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC D 90.NONE 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED I.SPILL BUCKET 3.STRIKER PLATEBO OM PROTECTOR 4.CONTAINMENT SUMP 45la-c VII.UNDER MSPENSER CON AINMENT(U C) CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOLE WALL ❑ 3.NO DISPENSERS [:190.NONE ren r. 469a CONSTRUCTION MATERIAL I.STEEL 4.FIBERGLASS [:I] 10.RI D PLASTIC ❑ 99.OTHER(Specify) 469b-c VIII. CORROSION PR ECTION STEEL COMPONENT PROTECTION [:12.SACRIFICIAL ANODE(S) LED] 4.IMP,ESSED CURRENT6.ISOLATION ... ;_�; 448. IX. APPLICANT SIG ATURE "s" CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is ,,e;.,Iccurate, and in full compliance with legal requirements. APPLICANT SIGNATURE DATE Z /L{ J ��. 430. APPLICANT NAME(print) 471. PLI i E / 472 J 144 <� l �� n s UPCF UST-B-1/2 Rev.(12/2007)