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UNIFIED PROGRAM CONSOLIDATED FORINT <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) <br /> TYPE OF ACTION (Cliecic one item only. Foran UST permanent closure or removal,complete only this section and Sections I,I1,111,IV,and IX below) 430 <br /> ❑ h NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> ❑ 6.'TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SrrE ❑ 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 4306 <br /> L FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) ? F. <br /> t <br /> BUSINESS NAME(Same as FACILFTY NAME or DBA-Doing Business As) 3 <br /> BUSINESS SITE ADDRESS 703 CI'T'Y 104 <br /> II.TANK DESCRIPTION <br />} TANK ID 432 TANK MANUFACTURER 433 TANK CONFIGURATION: TMSTANKTS. 434 - <br /> Tank 46 Xerxes ®I.A STAND-ALONE TANK <br /> 7 [_1 2.ONE IN A COMPARTMENTED UNIT. <br /> Corn lcic enc page for ea.],cop artment in the unit <br /> 1 DATE UST SYSTEM INS'T'ALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT -037 <br /> III.TANK USE AND CONTENTS <br /> TANK USE ❑ In MO'T'OR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ la AVIATION FUELING 439 <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] <br /> ❑ <br /> 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): D100 439a <br /> CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ Ih.PREMIUM UNLEADED 440 <br /> ❑ 3.DIESEL ❑ 5..TET FUEL ❑ 6.AVIATION GAS <br /> ❑ S,PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a <br /> NON-PFTROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> 11.OTHER NON-PETROLEUM(Specify):_B100 4406 - <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ I.SINGLE WALL El 2.DOUBLE WALL ❑ 95.UNKNOWN 449 <br /> y PRIMARY CONTAINMENT ❑ L STEEL El 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify) 445a <br /> OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ® 3.FILL TUBE SHUT-OFF VALVE 452, <br /> E:1I 4.TANK MEETS REQUIREMENTS FOR EXEMPTION NTION EQUIPm ENT <br /> V. PRODUCT/WAST G CONSTRUCTION <br /> PIPING CONSTRUCTION ❑1.SINGLE-WALLED ®2.DOUBLE-W LLED ❑99.OTHER 460 <br /> SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY U1 3.CONVENTIONAL SUCTION ❑ '4. AFE SUCTION[23 CCR§2636(a)(3)1 458 <br /> PRIMARY CONTAINMENT ❑ L STEEL El 4.FIBERGLASS ❑ S.FLEXIBLE 0,RIGID PLASTIC 464 <br /> ❑ 90.NONE ❑ 95.UNKNOWNTHER(Specify): 464a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL El 2.DOUBLE WALL ❑ 90-NONE 464d <br /> VI.VENT,VAPOR RECOVERY(VR)AND RISER 1 FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL R1 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e <br /> 464.1 <br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ W.OTHER(Specify) 464f <br /> 464fl <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC El 90.NONE ❑ 99.OTHER(Specify) 4641; <br /> 464 I <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ C FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h <br /> 464hl <br /> VENT PIPING TRANSITION SUMP TYPE ❑ T.SINGLE WALL ® 2.DOUBLE WALL ❑ 90.NONE 464i, <br /> RISER PRIMARY CONTAINMENT E] I.STEEL ❑ 4.FIBERGLASS ❑ 10_RIGID PLASTIC ❑ 90.NONE D 99 OTHER(Specify) 4641 <br /> 464fl <br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL E] 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k <br /> 464k1 <br /> FILL COMPONENTS INSTALLED 1.SPILL BUCKET El 3.STRIKER PLATE/BOTTOM PROTECTOR El 4.CONTAINMENT SUMP 45[a-c <br /> VII.UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ❑ 1,SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 46% <br /> CONSTRUCTION MATERIAL El1.STEEL F] 4.FIBERGLASS El10.RIGID PLASTIC E] 99.OTHER(Specify) 4696-c <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 449. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST"system 1s compatible with the hazardous substance stored and that the information provided herein is true,accurate, <br /> and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 470' <br /> y <br /> APPLICANT NAME(print) 471. APPLICANT TITLE 472. <br /> UPCF UST-B-112 Rev.(1212007) <br /> t <br />