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UNIFIED PROGRAM CONSOLIDATED FORM <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 /> ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 4300 DATE EXISTING UST DISCOVERED: 4306 <br /> 1. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) <br /> BUS11'rIESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 <br /> L 5 �� <br /> BUSINESS SITE ADDRESS l03 CITY 1,k�LLn A� l0q <br /> II.TANK DESCRIPTION 11 F a l <br /> TANK 4IJD# / r 432 TANK MANUFACTURER 433 TANK CONFIGURAI]ON: THISTANKIS 434 <br /> TROJ�V 09 rQ VJ �O� �2.ONE N A COMPARTMENTED UNIT. <br /> C-1-- efor each com anment in the mit. <br /> DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 <br /> III.TANK USE AND CONTENTS <br /> TANK USE la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic..4V L\TION FUELING 439 <br /> 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Iadudce Used(M) ❑ 5.EMERGENCY GENERATOR FLEL[HSC§2528I5(c)I <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a <br /> CONTENTS PETROLEUM: 2,Ia.REGULAR UNLEADED ❑ 1c.MIDGRADE UNLEADED <br /> ❑ IF.PREMIUM UNLEADED 440 <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 449. <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ IL OTHER NON-PETROLEUM(S cci 4406 <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ ].SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 <br /> PRIMARY CONTAINMENT L STEEL t FIBERGLASS ❑ 6.INTERNAL BLADDER 444 <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444. <br /> SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 <br /> ❑ 90.NONE 95.UNKNOWN ❑99.OTHERS city): 445a <br /> OVERFILL PREVENTION ❑ I.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ® 3.FILL TUBE SHUT-OFF VALVE 052. <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION El 1.SINGLE-WALLED B2.DOUBLE-WALLED 099.OTHER 460 <br /> SYSTEM TYPE N I.PRESSURE i.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2686(.)(3)] 458 <br /> PRIMARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ S.FLEXIBLE <br /> ❑ 10.RIGID PLASTIC 464 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. <br /> SECONDARY CONTAINMENT ❑ I.STEEL 19 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 40c <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d <br /> V1.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ,® I.STEEL ❑ 4.FIBERGLASS Ll10.RIGID PLASTIC EI90.NONE ❑ 99.OTHER(Specify) 464c <br /> VENT SECONDARY CONTAINMENT L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 6461 <br /> 99.OTHER(Specify) 464f <br /> 464f1 <br /> VR PRIMARY CONTAINMENT L STEEL II 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464g <br /> _ /' 4641 <br /> VR SECONDARY CONTAINMENT L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h <br /> 464h1 <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 4641. <br /> RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464, <br /> RISER SECONDARY CONTAINMENT 1.STEEL [1464'I 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 48k <br /> 464k] <br /> FILL COMPONENTS INSTALLED 1.SPILL BUCKET jd 3.STRIKER PLATUBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c <br /> V1I.UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469. <br /> CONSTRUCTION MATERIAL YIN L STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696-c <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448- <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is truc`;.ahcnra[e, <br /> and in full com fiance with legal rerIpirements. _ <br /> APPLICANT SIGNATURE / A/ DATE 470. <br /> APPLICANT NAME(print 471' APPLICANT TITLE402 AM AILI!b - <br /> m o 1�e�slv><v r <br /> f <br /> UPCF UST-B-1/2 <br /> Rev..(I2/2j <br />