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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK �1\ OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) \ l TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,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 ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a I DATE EXISTING UST DISCOVERED: 4306 L FACILITY INFORMATION FACILITY ID#(Agency Use Only) D _ _ I rL BUSINESS NASame as FACILIIT NAMEfy IJBA-Doing Business As) 3 BUSINESS SITE ADDRESS +'T`r {,�1/� 103CITY n '� too II.TANK DESCRIPTION �l TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 1.AST IN C TANK N ` �2.ONE IN A COMPARTMENTED UNIT. Complete one pap for ewl ompmtnent in the writ. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMB TMENTS 11 THE UNIT 437 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(Inch les Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: e.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED [I 95. PREMIUM UNLEADED 440 t3.DIESEL [15.JET FUEL ❑ 6.AVIATION GAS .PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL n .DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.INFERNAL BLADDER 444 ❑ 7.STEEL+INTE A LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S i ): 444a SECONDARY CONTAINMENT ❑ 1.STEEL 4 FIBERGLASS [16.EXTERIOR MEMBRANE LINER Ll7.JACKETED 445 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S ): 445a OVERFILL PREVENTION .AUDIBLE&VISUAL ALARMS ALL 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 DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE I.PRESSURE 2.GRAVITY [13.CONVENTIONAL SUCTION ❑4.SAFE SUCTION[23 CCR§2636(aX3)] 458 PRIMARY CONTAINMENT L STEEL FIBERGLASS ❑ 8.FLEXIBLE El 10.RIGID PLASTIC 464 ❑ 90.NONE 5.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE 95.UNKNOWN 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL _ 2.DOUBLE WALL ❑90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND kISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL ; 4.FIBERGLASS D 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ' 90.NONE E] 99.OTHER(Specify) 464g // v_ 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC >00.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90. ONE 464i. RISER PRIMARY CONTAINMENT I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC NONE 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC7090.NONE 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATEBOTTOM PROTECTOR ' CONTAINMENT SUMP 451a c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WAI.L .DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL A 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4691:c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT .ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION:I certify that this UST Wstem is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full cow li ce AWlegal requirements. APPLIC DATE f 470. APPLICANT N � ) �� 471. APPLICANT TITLE 472 1 � v UPCF UST-B-1/2 Rev.(12/2007)