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i 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,II,III,IV,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 EXISTING UST DISCOVERED: 430b I. FACILITY INFOIWATION FACILITY ID#(Agency Use Only) _ �l BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) v V V f P' l rj BUSINEIS SITE AD,I?RESS 103 CITY0' L /t20i W XV f�-T-o 1`) ,,. II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK ISSANJOAQUINCOUNTY 434 I-� S`19 �( Z0-y I��.r.❑�1.A STAND-ALONE TANK ONE IN A COMPARTMENTED UNIT. ENVIRONMENTAL ✓`V�s I Complete one page for each compartment in the DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 00 III.TANK'USE AND CONTENTS TANK USE CS la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc.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: ❑ 1a.REGULAR UNLEADED ►c.MIDGRADE UNLEADED ❑ lb.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 CONSTROCTION TYPE OF TANK ❑ I.SINGLE WALL IS 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL W 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHERS eci ): 445a OVERFILL PREVENTION �f I.AUDIBLE 8t VISUAL ALARMS [12.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. (� 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPINGICONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED ®2.DOUBLE-WALLED [:199.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR§2636(x)(3)) 458 PRIMARY CONTAINMENT I.STEEL ®.4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL [4.FIBERGLASS [1 8.8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/ ILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL 1&4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464x1 VENT SECONDARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC 19 90.NONE 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT 1.STEEL 09 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Spccify) 464s 464g] VR SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC a 90.NONE 0 99.OTHER(Specify) 464h 464h VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4641. RISER PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 464'1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL 19 4.FIBERGLASS ❑ 10.RIGID PLASTIC EJ 90.NONE 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED I.SPILL BUCKET CZ 3.STRIKER PLATEBOTTOM PROTECTOR ® 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CON AINMENT(UDC) CONSTRUCTION TYPE I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC El 99.OTHER(Specify) 4696-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT �!L 6.ISOLATION 448. IX. APPLICANT SIG ATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in fill . a e vire ts. APPLICANT SIGNATU DATE 470. APPLICANT NAME(print). 471' APPLICANT TITLE �Ce1 z UPCF UST-B-1/2 Rev.(12/2007)