Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM al <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) <br /> 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 <br /> ❑ L NEW PERMIT ❑ 3.RENEWAL PERMITS.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE El 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430, I DATE EXISTING UST DISCOVERED: 43% <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) 1 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business AS) 3 <br /> Ldfh46 C-42)UM1-9tl S7/-f7 O" <br /> BUSINESS SITE ADDRES 103 <br /> iii T i L6_AAA-ro Lmu CITY Lb(b 00 <br /> H.TANK DESCRIPTION <br /> TANK ID# 432 TANK ACTHRER 433 TA CONFIGURATION: THIS TANK IS 434 <br /> Tf� ��// .ASTAND-ALONE TANK <br /> /I D �OFj�2� (/� S ( ✓ 2.ONE IN A COMPARTMENTED UNff. <br /> erc one fineech mtlw�e <br /> DATE UST }r Ur 435 TANK CAPAC 436 NUMBER OF COMPARMENTS_I THE UNIT 437 IN <br /> S <br /> M.TANK USE AND CONTENTS <br /> TANK USE la.MOTOR VEHICLE FUELING [IIb.MARINA FUELING ❑ 1..AVIATION FUELING 439 <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(h tl Us at) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(,H <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a <br /> CONTENTS PETROLEUM: la REGULAR UNLEADED ❑ I,.MIDGRADE UNLEADED [I III.PREMIUM UNLEADED 4b <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 4/t4 <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUM 5 4406 <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 <br /> PRIMARY CONTAINMENT 04 STEEL - 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 <br /> TEEL+INTERNA L&N ❑ 95.UNKNOWN ❑ 99.OTHER (S 4444 <br /> SECONDARY CONTAINMENT '� c .STEEL FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 <br /> u 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445. <br /> OVERFILL PREVENTION 1.AUDIBLE @.VISUAL ALARMS El 2.BALL FLOAT 3.FILL TUBE SRUT-0FF VALVE 452. <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION [11.SINGLE-WALLED 2.DOUBLE-WALLED [199.OTHER 460 <br /> SYSTEM TVPE I.PRESSURE ❑ .GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAF-SUCTION 23 CCR§2636(aX3)j 458 <br /> PRIMARY CONTAINMENT 1.STEEL .FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 <br /> ❑ 90.NONE T3 95.UNKNOWN ❑ 99.OTHER(Specify): 4644 <br /> SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b <br /> ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Sp <br /> ? ecify): 464 <br /> PIPINGURBINE CONTAINMENT SUMP TYPE I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 <br /> VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 11 10.RIGID PLASTIC 90.NONE E3 99.OTHER(Specify)Ok <br /> 464 <br /> 4641 <br /> VENT SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS E310.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464f <br /> 4640 <br /> VR PRIMARY CONTAINMENT D L STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464g <br /> VR SECONDARY CONTAINMENT [I I.STEEL E94.FIBERGLASS 10.RIGID469 1 PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464h <br /> 464b1 <br /> VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 464i. <br /> RISER PRIMARY CONTAINMENT to 1.STEEL U 4.FIBERGLASS LJ 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4641 <br /> 464'1 <br /> RISER SECONDARY CONTAINMENT0 1.STEEL 4.FIBERGLASS 0 I0.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464t <br /> 469YI <br /> FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATEIBOTTOM PROTECTOR 4.CONTAINMENT SUMP 4514, <br /> VII.UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE .SINGLE WALK 2.DOU13LE WALL ❑ 3.NO DISPENSERS ❑ W.NONE 46A <br /> CONSTRUCTION MATERIAL STEEL I.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 99.OTHER(Specify) 469bc <br /> CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT .ISOLATION 448 <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify th this UST system' compatible with the hazardous substance stared sod that the information provided herein is true,sceurate, <br /> and in full mingance wfth I a ulrements. <br /> APPLICANT SIGNATURE � DATE (ti I�f0 (� 430_ <br /> APPLICANT NAME(print) S"6 <br /> "F 6160 APPLICANT TITLE / o,,n _„/7 472. <br /> UPCF UST-B-1/L i y Q (Af[��/ Rev.(TZIZ 0'n' .� <br /> d.a_1 <br />