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FIED PROGRAM CONSOLIDATED File UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMAT e roan Per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,II; 11 IV,and 1X ILcl�w j ^ A-_ 41, ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ S.UST REMOVAL ' DATE UST PERMANENTLY CLOSED: ...a I DATE EXISTING UST DISCOVERED b' 4106 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) W C UiM 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) -1 �l'ar•�T(y�K,!1- BUSINESS SITE ADDRESS 103 1 CITY 104 II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 E❑1.ASTAND-ALONE TANK A V V�, ONE M A COMPARTMENTED UNIT. 1 .V Ca lete one a for cach com men[in the unit. DATE UPI INSTALLED 435 TANK CAPACITY IN GALL 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 O--coo aU III.TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ElIh.MARINA FUELING E] Ic.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ S.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: a.REGULAR UNLEADED ❑ la MIDGRADE UNLEADED �BD 440 3.DIESEL ❑ 5.JET FUEL 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440. NON-PETROLEUM:❑ T USED OIL ❑ I0.ETHANOL ❑ 11.OTHER NON-PETROLEUM(S ecify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ L SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT L STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444. SECONDARY CONTAINMENT ❑ L STEEL .FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445. OVERFILL PREVENTION El 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOA7 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PROD CT/WASTE PIPING CONSTRUCTION PIPING CONS I RUC ION El 1.SINGLE-WALLED 2.DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE ------------0-1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(.)(3)] 458 PRIMARY CONTAINMENT ❑ L STEEL JY4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 46,11, ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 461c PIPING/TURBINE CONTAINM EN F SUMP TYPE 93'I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE NPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464, 464,1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 46411 VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464g 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4641 RISER PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED ❑ I.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451.-c VII.UNDER DISPENSER CONTAINMENT(UDC) g CONSTRUCTION IYPP. I.SINGLE WAL ❑ 2.DOUBLE WALL ❑ -469a ❑ 3.NO DISPENSERS 90.NONE CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4b9bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448- IX. APPLICANT SIGNATURE S' r;1 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 / /v ��' 70, APPLICANT NAME(print) •//'j� J o 4�I- APPLICANT T7ITLE b /�/./ y/// 4J2- UPCF UST-B-1/2 /f►' /V (/(y /✓G�� Rev.(12/2007)