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UNIFIED PROGRAM CONSOLIDATED FORf I (p� UNDERGROUNDSTORAGETANK 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 1,If,III,IV,and IX below) 430 ❑ L NE W PERMIT ® 3.RENEWAL PERMIT ❑ 5.C14ANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4101 DATE EXISTING UST DISCOVERED: 4301, I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) I I q 14,7I BUSINESS NAME(Same as F 1LIT NAM47 -DU(oing Business As) 3 BUS(,ES S DISE.Sr C OC�- 03 CITY �n_ nN`Crn I, I U.TANK DESCRIPTIONII/ ' I TANK 1rD#ar 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THISTANKIS 434 14 Q I 006 OWC-Mf / 0 �� [12.IONE A COMPARTMENTED UNIT. VVV"`��"' l� Comlge me (ora6 eMaaaM=in the ML T T TAL6ED 435 TANK CAPA IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 l 1 0o 0 III.TANK USE AND CONTENTS TANK USE Ia.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 .CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Indu&a Ux Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ 1c.MIDGRADE UNLEADEDIb.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-PETROLEUMS i : 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL IN 2.DOUBLE WALL ❑ 95.UNKNOWN 441 PRIMARY CONTAIJ E ❑ 1.STEEL Pir 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7. STEEL,INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S i ): 444. SECONDARY CONTAINMENT ❑ 1.STEEL R3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 El90.NONE D 95.UNKNOWN ❑99.OTHERS i ): 4451 OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. 4.TANK MEETS REQUIREMENTS F R EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑I.SINGLE-WALLED Of 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR§2636(.x3)1 458 PRIMARY CONTANMEM ❑ 1.STEEL 4.FIBERGLASS ❑ &FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464. SECONDARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 'tMb ❑ 90.NONE D 95.UNKNOWN ❑ 99.OTHER(Specify): 4Me PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT L1 1.STEEL CKTFIBERGLASS D 10.RIGID PLASTIC El 90.NONE ❑ 99.OTHER(Specify) 464e 46Mel VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 4644 VR PRIMARY CONTAINMENT S L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4646 464 1 VR SECONDARY CONTAINMENT ❑ I.STEEL '.FIBERGLASS ❑ 10.RIGID PLASTIC W 90.NONE ❑ 99.OTHER(Specify) 464h Ohl VENT PIPING TRANSITION SUMP TYPE I.SINGLE WALL ❑ 2.DOUBLE WALL C9 90.NONE 4641. RISER PRIMARY CONTAINMENT 0a 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC LJ 90.NONE U 99.OTHER(Specify) 't0i 464'i RISER SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS Ej 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4Rk 464kl FILL COMPONENTS INSTALLED I.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 451a-c. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE L SINGLE WA L 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 46% CONSTRUCTION MATERIAL 1.STEEL IJ5,4.FIBERGLASS LI 10.RIGIDPLASTIC ❑ 99.OTHER(S ify) 4691,c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this US stem is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in mplilax0d with legal requixodents. APPLICANT SIGNA DATE 470' 0 �- APPLICANT NAME(print) L APPLICANT TITLE �, t n�il/1 _ 4n. Jg r.Z S / un-IL I L I A- UPCF UST-B-1/2 Rev.(12/21107)