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TIED PROGRAM CONSOLIDATED F UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. For an VST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IN below) 430 ❑ L7�EW PERMIT 3.RENEWAL PERMIT' - ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMC)iQARY-("1ST CLOS- RE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DA I F LSF PERMANFNFLY CLOSED: a DATE EXISTING US"I DISCOVERED: 4306 i I. FACILITY INFORMATION FA(ILITY ID#(Agencj Use Onlh) _ I BUSINESS NA ( a Q.ITY NAME or DBA-Doing Business As) r_]., _ 3 < ✓`may7�/� BUSINESS SI s (-• 103 CITY e� n� 104 "1 I 'b1ifiaEf,T R.TANK DESCRIPTION TANK ID# a32 TANK MANUFACTURER 433 T.ANKCONFIGURATION: THIS TANK IS 434 b ❑ 1.A STAND-ALONE TANK ®$.ONE M A COMPARTMENTED UNIT. Co Tete one page for each connincurnnent in the unit DATE UST SYSTEM INSTALLED 435 TANK CA SITY�ALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 III.TANK USE AND CONTENTS TANK USE Erla.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ 1c.AVIAIIONFUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ S.EMERGENCY GENERATOR FUEL(HSC§25281.5(e)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439. CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED Of1b.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL LI 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 449a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11 OTHER NON-PETROLEUM(S ecify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ .SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL WING [195.UNKNOWN [399.OTHER (Specify): 4441 SECONDARY CONTAINMENT El 1.STEEL .FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER(Specify): 445a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT .FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVE.RI'ILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION SING IT-WALLED 2.DOUBLE-WALLED El 99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2. RAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(x)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE .UNKNOWN [199.OTHER(Stecify): 464• SECONDARY CONTAINMENT ElL STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 1..UNKNOWN [399.OTHER(Specify): 4641 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 ❑ LSTEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ LSTEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641' 464n VR PRIMARY CONTAINMENT ❑ LSTEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464 I VR SECONDARY CONTAINMENT ❑ LSTEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 4Mhl VENT PIPING TRANSITION SUMP TYPE ❑ U SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464i. RISER PRIMARY CONTAINMENT ❑ LSTEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464i 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 ❑ 1 STRIKER PLATE/BO"F"FOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451s< VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 4691 CONSTRUCTION MATERIAL ❑ LSTEEL 4.HBERG LASS ❑ IO.RIGID PLAS'I IC ❑ 99.O'1'HE12(specify) 46911 VIII. CORROSION PROTECTION STEELCOMPONENI PROTECTION ❑ 2.SACRIFICIALANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 44S 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 / L 470 cS Q APPLICANT NAME(print) U/• �/� 471' APPLICANT TITLE /� // 472_ Q, al UPCF UST-B-1/2 (� �" Rev.(12/2007)