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FIED PROGRAM CONSOLIDATED F UNDERGROUND STORAGE TANK ' a� _ -, OPERATING PERMIT APPLICATION-TANK INFORMATION(One p US � TYPE OF ACTION (Check one item only. For an U T permanent closure or removal,complete only this section and Sections 1,11,III,IV,and w d30 ❑ 1.NEW PERMIT RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION mss , ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL Ao, y DATE UST PERMANENTLY CLOSED: 4304 DATE EXISTING UST DISCOVERED: f ° I. FACILITY INFORMATION U10 FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) T ,J y e� /'e (& 5, �;' 3 BUSINESS SITE ADDRESS �) ' 103 CRY 7 n / (f 107 - IL TANK DESCRIPTION f TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 ❑I.A STAND-ALONE TANK 6 ❑2.ONE M A COMPARTMENTED UNIT. Co let,one a for each co artmem in she unix. DAT S SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT437 7 o-olt-cro T III.TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 W3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ T USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(S ccifu): 4406 IV. TANK CONSTRUCTION TYNE OF TANK .INGLE WALL BL DOUE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT I.99sl6! S ❑ 6.INTERNAL BLADDER 444 7.STEEL+INTERNAL VINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL E31.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑919.OTHER(Specify) 4454 OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS [12.BALL FLOAT : .FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUC /WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1 SINGLE-WALLED .DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION Ll4.SAFE SUCTION 23 CCR§2636(.)(31] 458 ❑ PRIMARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 9 UNKNOWN [:199.OTHER(Specify): 464. SECONDARY CONTAINMENT [11.STEEL IT 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE .SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464c 664e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 464PI VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4646 464 I VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4641. RISER PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464, 464] RISER SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451x-, VII.UNDER DISPENSER CONTAINMENT(UDC) 1. n CONSTRUCTION TYPE SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 4694 CONSTRUCTION MATERIAL ❑ L STEEL Er4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2_SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE <== CERTIFICATION: 1 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 / / /'; 2 DATE 4J0 APPLICANT NAME(print) // 411. APPLICANT TITLE i7UJ � / 472 UPCF UST-13-1/2 6 [/ Rev.(12/2007)