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9 0 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 ❑ L NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ T UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430' I DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 3 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 L @ *I �0 BUSINESS SITE ADDRESS CITY 104 II.TANK DESCRIPTION TANK ID `v n# //``�� 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 050 56Yo -. ( '�&lw)S 9I.A STAND-ALONE TANK 11 LL ' ❑2.ONE IN A COMPARTMENTED UNIT. Com fete ane Paice fut each comunment in the wit DATE UST SYSTEM INSTALLED 435 TANK CA ACIITTY,{N GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 III.TANK USE AND CONTENTS TANK USEry Ia.MOTOR VEHICLE FUELING ❑ If.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL(HSC§25281.5(,)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ In.MIDGRADE UNLEADED JR Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 4408 NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(S eci ): 440b IV. TANK CONSTRUCTION TYPE OFTANK ❑ 1.SINGLE WALL 51 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT I.STEEL T 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 7.STEEL+IN I'ERN'AL LINING ❑ 95.UNKNOWN E399.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL 513.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION ❑ I.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION Cl I.SINGLE-WALLED C9 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR g2636(ap3)] 458 PRIMARY CONTAINMENT ❑ I.STEEL Eff 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ to.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ElL STEEL &4.FIBERGLASS ❑ 8.FLEXIBLE 10.RIGID PLASTIC 4646 Cl 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464, PIPING/TURBINE CONTAINMENT SUMPTYPE WE 1.SINGLE WALL G.DOUBLE WALL ❑ 90.NONE aWd VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT P] L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464¢ 464el VENT SECONDARY CONTAINMENT ... LSTEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464E 4Mn VR PRIMARY CONTAINMENT I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464g VR SECONDARY CONTAINMENT J64 L STEEL ❑ 4.FIBERGLASS 464 1 ❑ l0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT pI L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464j 61 1 RISER SECONDARY CONTAINMENT LSTEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ W.NONE ❑ 99.OTHER(Specify) 464k 4641 FILL COMPONENTS INSTALLED5k I.SPILL BUCKET AN 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMEN"1'SUMP 451.-c VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 4698 CONSTRUCTION MATERIAL ❑ L STEEL ❑ 4.FIBERGLASS 9 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696, VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ G ISOLATION "<'' 448_ IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the ha cardaus substance stored and that the information provided herein is true,accurate, and in full compliance with legal re uire ents. APPLICANT SIGNATUR DATE 470 APPLICANT NAME(print) 411' APPLICANT TITLE Q 472. N L 0 1 QF.S I GF'�'f . UPCF UST-B-1/2 Rev.(12/2007)