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laea,,FIED PROGRAM CONSOLIDATED FOIA 170 4 <br /> UNDERGROUND STORAGE TANK �!S/' 3I� <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One former UST) <br /> TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11,111,IV,and IX below) 430. <br /> ❑ I.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> E] 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 030% DATE EXISTING UST DISCOVERED: 4306. <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3' <br /> G GO O <br /> BUSINESS SITE ADD S 103. CITY 104' <br /> LfLiiiB )V . <br /> SO <br /> II. TANK DESCRIPTION <br /> TANK ID# 432, TANK MANUFACTURER 433- TANK CONFIGURATION:THIS TANK IS 034, <br /> g 1.A STAND-ALONE TANK Complete ove page for mch <br /> O O O <br /> 2.ONE IN A COMPARTMENTED UNIT compa acuil in We wit. <br /> DATE UST SYSTEM INSTALLED TANK CAPACITY IN GAL S 436. NUMBER OF COMPARTMENTS IN THE UNIT a37, <br /> fl4fmah C `I o 1 Z.0o L <br /> III. TANK USE AND CONTENTS <br /> TANK USE $ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ IC.AVIATION FUELING 439. <br /> -tl 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Ivdudes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] <br /> ❑ <br /> 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439. <br /> CONTENTS PETROLEUM: ❑ 1.REGULAR UNLEADED ❑ Ic.MIDCRADE UNLEADED ib.PREMIUM UNLEADED 440. <br /> ❑ 3.DIESEL E35.JET FUEL 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440. <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ <br /> 11.OTHER NON-PETROLEUM(Specify): 4406. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN _ 443. <br /> PRIMARY CONTAINMENT ❑ L STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER a44. <br /> _ ❑ 7.STEEL+INTERN LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): a44a_ <br /> SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. <br /> ❑ 90.NONE 95.UNKNOWN ❑99.OTHER(Specify): usa <br /> OVERFILL PREVENTION ® LAUDIBLE&VISUALALARMS ❑ 2.BALL FLOAT a 3.FILL TUBE SHUT-OFF VALVE 452. <br /> n 4.TANK MEETS RE UIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑ 1.SINGLE WALL M 2.DOUBLE WALL ❑ 99.OTHER _ 460. <br /> SYSTEM TYPE X 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION (] 4.SAFE SUCTION 123 CCR§2636(aX3) 458' <br /> PRIMARY CONTAINMENT ❑ 1.STEEL W 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464. <br /> ❑ 90.NONE_ ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL X 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4640 <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE a6aa. <br /> VI. VENT,VAPOR RECOVERY (VR) AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT PQ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC o❑ 90.NONE [j99.OTHER(Specify): [ <br /> VENT SECONDARY CONTAINMENT [31.STEEL [14.FIBERGLASS [310.RIGID PTASTIC W 90.NONE ❑ 99.OTHER(Specify): 446Fl. <br /> VR PRIMARY CONTAINMENT ja 1.STEEL. ❑ 4.FIBERGLASS ❑ 10.RIGIDPIASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): e: <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ HLRIGIDPLASTIC W 90.NONE ❑ 99.OTHER(Specify): g6�4h1 <br /> VENT PIPING TRANSITION SUMP TYPE j] 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE °641. <br /> RISER PRIMARY CONTAINMENT Ia 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4&11L <br /> RISER SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC IR 90.NONE ❑ 99.OTHER(Specify): 464k. <br /> 46441. <br /> FILL COMPONENTS INSTALLED JO 1.SPILL BUCKET ❑ 3.STRIKER PLATFIBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a-c. <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE XILSINGLE WALL ❑ 2 DOUBLE WALL [13.NO DISPENSERS ❑_90 NONE 469x. <br /> CONSTRUCTION MATERIAL El 1.STEEL [14.FIBERGLASS El10.RIGID PLASTIC ❑ 99.OTHER(Specify) aY n 469c <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information'provided herein is true, <br /> accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 4J0. <br /> - - 09 <br /> APPLICANT NAME(print) U u y 471' APPLICANT TITLE !1 W 4n. <br /> UPCF UST-8 Rev.(12/2007)-1/2 www.unidocs.org �l <br />