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UNIFIED PROGRAM CONSOLIDATED FORM P C 23 D UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One fo m per IsINK 01161 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 belo 4° ❑ I.NEW PERMIT ❑ 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION 1 9 ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE S.UST REMOVAL l 430 DATE UST PERMANENTLY CLOSED: " T DAE EXISTING UST DISCOVERED: I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) - - BUSINE S NAME(Same Aa I �GNAME or DBA-Doing Business As) ILO 2 S O� 3 BUSIN S I AD RESS K• 1 103 CITY '(r J I°4 A II.TANK DESCRIPTION TANK IDk 432 TANK MANUFACTURER 433 TANK CONF'IGURAT'ION: THIS'TANK IS 434 31 / ASTAND-ALONE TANK U7 N h N M 2.ONE A COMPARTMENTED UNIT. Complete one a efor each com artnient in the mit. DATE UST SYS LEM INSTALLED 435 TANK-LAPACITY IN LLO S 036 NUMBER OF COMPATMEN'PS IN THE UNIT 437 Q0 ill.TANK USE AND CONTENTS TANK USE ❑ Ia.MOTOR VEHICLE FULLING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CI I EMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE nulcd,a Wd oip ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)I ❑ 6.01HER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439. CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ I c.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.O7"HER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.0"I'HERNON-PETROLEUMS eci'): 4406 IV. TANK CONSTRUCTION l'YPE OF TANK ❑ LSINGLE N'ALI. ❑ 2.DOODLE WALL ❑ 95.UNRNOWN 443 PRIMARY CONTAINMENT ❑ I.SN EL ❑ 3.FIBERGLASS ❑ &INTERNAL BLADDER 444 ❑ 7.STEEL I INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ I.S"H1:L Ll 3,FIBERGLASS ❑ 6.EXTERIOR MMBRANE LIN EER ❑ 7.JACKETED 445 [190.NON[ ❑ 95.UNKNOWN ❑99.OTHER(S ecifyF 445. OVERFILL PREVENTION ❑ I.AUDIBI,F&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SEWI-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPT ION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCT ION 1,SINGLE-WALLED El.DOUBLE-WALLED ❑940"11IER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY El3.CONVENTIONAL SUCTION EI 4,SAFE SUCTION[23 CCR§26361a1(3)I 458 PRIMARY CONTAINMENT ❑ 1.STEEL El 4.FIBERGLASS E] 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4641, ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1,SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d Vl.VENT,VAPOR RECOVERY(VR)AND RISER//FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT EI I.STEEL Ll 4.FIBERGLASS ❑ to RIGIDPLASHC' LJ9U.NONP. ❑ 99.0"fHER(Specify) 464! 46441 VENT SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4&V 464H VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4646 464.1 VR SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464h) VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464'_ RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464, 4641 RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ YL RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464kl FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION 1 YPE ❑ 1.SINGLE WALT. ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL. ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 99.OTHER(Specilj) 4696-c VIII. CORROSION PROTECTION S1'EEL COMPONENT PRO HELLION ❑ 2.SACRIFICIAL.ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE 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 full compliance with legal requirements. 470. APPLICANT SIGNATURE DATE APPLICANT NAME(print) 421' APPLICANT TITLE 472. UPCF UST-B-1/2 Rev.(12/2007)