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FIED PROGRAM CONSOLIDATED F UNDERGROUND STORAGE TANK OPER KT G PERMIT APPLICATION-TANK INFORMATION(one form per UST) TNACTION (Check on;iteul enly.- r an UST permanent closure or removal,complete only this section and Sections 1,II,111,IV,and IX below) 430 W PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PEA"N]ENSLOWSED. 4t0a DAT'F EXISTING UST DISCOVERED: 4301, I. FACILITY INFORMATION FACILITY ID,#(Agency Uil l BUSINESSjll% l":'.(SarftdTVJNLITY NAME or DBA-Doing Business As) 3 BUSINESS SITE ADDRESS 103 CITY 104 II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK C'ONFIGURAJ ION: TIHSTANKIS 434 ❑1.A STAND-ALONE TANK el ONE M DIT A COMPARTMENTED UNIT. o Cleone page for each wm NT the T. DATE UST SYSTEM INSTALLED 435 TANK CA CI YIN GA ONS 43 NUMBER OF COMPARTMENTS IN THE UNIT 437 ��Q 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§25291.5(ap ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ Is.REGULAR UNLEADED Me.MIDGRADE UNLEADED 440 ❑ 3.DIESEL 5.JET FUEL 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(S ecif L 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL .DOUBLE�NALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT I.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNA LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444. SECONDARY CONTAINMENT ❑ L STEEL Ej 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION [11.AUDIBLE&VISUAL ALARMS L12.BALL FLOAT .FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUC 1 WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ E SINGLE-WALLED .DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ GRAVITY N ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458 PRIMARY CONTAINMENT 0 I.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 454 ❑ 90.NONE ❑ 5.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 5.UNKNOWN ❑ 99.OTHER(Specify): 4Ne PIPING/TURBINE CONTAINMENT SUMP TYPE I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4Md 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) 464e 464el VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464( 46,111 VR PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4646 464 1 VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 4Mhl VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE W ALL ❑ 2.DOUBLE WALL El 90.NONE 4641 RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 4Nj1 RISER SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641, 464k1 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE I.SINGLE'AT ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469' CONSTRUCTION MATERIAL ❑ LSTEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469 VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 348 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,activate, and in full com fiance with legal requirements. APPLICANT SIGNATURE DATE /a. i20 APPLICANT NAME(print) Leif e'e f J 071 APPLICANT TITLE '` `/�,/ J12 UPCF UST-B-1/2 Rev.(12/2007)