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UNIFIED PROGRAM CONSOLIDATED FORM 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 I,E,III,IV,and IX below) 430 ❑ 1 NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE El 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 43a1, I. FACILITY INFORMATION FACILITY ID N(Agency Use Only) BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 OlL c BUSINESS SITE ADD SS103 CIT 10` L04 D2 II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: TIES TANK IS 434 .p 1.A STAND-ALONE TANK 1 A oai too r OW � co w't„^` ❑2.ONE INACOMPARTMENTEDUMT. S C. M`� 'l/ Com late ono a of OMP cam eENTEn U emit. DATE UST SYJTV TTALLED 635 TANK CAPACITY IN GALLONS ... NUMBER OF COMPARTMENTS IN THE UNIT 432 �11 ` M.TANK USE AND CONTENTS TANK USE ❑ Ia MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHFMCAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL WSC§25291.5(.)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN M99.OTHER(Specify): 439. CONTENTS PETROLEUM: ❑ in.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ 1b.PREMIUM UNLEADED 'No ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS [18.PETROLEUM BLEND FUEL J&9.OTHER PETROLEUM S eci 440e NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ I1.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 446 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ L STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE 95.UNKNOWN ❑99.OTHER(Specify): 445° OVERFILL PREVENTION I.AUDIBLE 86 VISUAL ALARMS ❑ 2.HALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED 2.DOUBLF WALLED [199.OTHER 460 SYSTEM TYPE ❑ L PRESSURE 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(.)(3)) 458 PRIMARY CONTAINMENT ❑ L STEEL IN 4.FIBERGLASS ❑ S.FLEXIBLE Cl 10.RIGID PLASTIC 664 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): d64a SECONDARY CONTAINMENT ❑ 1.STEEL X 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4641, ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER( Sin cify): 464c PIPINGfFURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL [12.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL ❑ 4.F®ERGLASS ❑ 10.RIGID PLASTIC Lj 90.NONE Ll 99.OTHER(Specify) 464• 464ef VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC A 90.NONE ❑ 99.OTHER(Specify) 4641' 4MfI VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 4646 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 464'. RISER PRIMARY CONTANME7T ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464) 64'1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 9L.90.NONE ❑ 99.OTHER(Specify) 464k 464kl FILL COMPONENTS INSTALLED 19 1.SPILL BUCKET ❑ 3.STRIKER PLATEIBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS 90.NONE 6698 CONSTRUCTION MATERIA[, ❑ 1.STEEL [14.FIBERGLASS [110.RIGID PLASTIC Li99.OTHER(S 4696. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 648' 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 re menta. 470. APPLICANT SIGNATURE DATE r APPLICANT NAME(print) �� 471. APPLICANT TITL V a7z. UPCF UST-B-12 i� Rev.(122007)