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UNIFIED PROGRAM CONSOLIDATED FORM Y Z 3Lb UNDERGROUND STORAGE TANK L OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per 6 111 TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,II,III,IV,and IX below) 430 F11.NEW PERMIT El3.RENEWAL PERMIT [15.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE S.UST REMOVAL �I? DATE UST PERMANENTLY CLOSED: 431a DATE EXISTING LIT DISCOVERED: mob I. FACILITY INFORMATION F _ 1 FACILITY ID#(Agency Use Only) A � p BUSINE S NAME(�yr.ag.FACI� AME or DBA-Doing Business As) �1 �nV rJ�J 3 BUSINE SST DDDRESS S GY 103 CITY NI(„ /�('�J/L. 104 _(/ I1.TANK DESCRIPTION C /(� TANK IDN 432 TANK MANUFACTURER 411 TANK CONFIGURATION: THISTANKIS 434 W.ASTAND-ALONE TANK q 50-Ag Z3 1V P �vvy [12.ONE,IN A COMPARTMENTED UNIT. Com leleone a For each com anment is the.aa DATE UST SYSTEM INSTALLED 435 TAN trlb ITY I GpLJpNS 436 NUMBER OF COMP RTMENTS IN THE UNIT m7 111.TANK USE AND CONTENTS TANK USE 1a.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ I AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE Ondudes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL HISC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439,, CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ He.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440, NON-PETROLEUM:❑ 7,USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(S ecif): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL ❑ 2.DOUBLE WALT, ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ I.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER 5 ci ): 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 ❑ I.SINGLE-WALLED [12.DOUBLE-WALLED ❑99.OT HER 460 SYSTEM TYPE ❑ I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Speeify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENTSUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d V1.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ l0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464,. 4Mel VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4mh 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ 7.SINGLE WALL [12.DOUBLE WALL El64 90.NONE 4 ', RISER PRIMARY CONTAINMENT ❑ 7.STEEL ❑ 4.FIBERGLASS ❑ I0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 464 1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL,COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER IT AT'EBOTTOM PROTECTOR ❑ 4,CONTAINMENT SUMP VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONST RUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ IO.RIGIDPLASTIC ❑ 99.OTHER(Specify) 469bo VIII. CORROSION PROTECTION S'ILET,COMPONENT PROTECTION El 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. APPLICANT SIGNATURE DATE azo APPLICANT NAME(print) 491' APPLICANT TITLE 472. UPCF UST-B-1/2 Rev.(12/2007)