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o � UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections L 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 S.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4` DATE EXISTING UST DISCOVERED: 43ob L FACILITY INFORMATION FACILITY B)#(Agency Use Only) /' �,j O 0:7�, BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 P C�l/10 I-f BUSINESS ITE ADD' S /� m CITY 7 sT! -�4' yG /iC i L� !/(i/1 C/( l/C as IL TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK TS 434 ❑1. AND-ALONE TANK /'t•®J`��Oc- .ONE IN A COMPARTMENTED UNIT. C aeone [aarh ciarc unit ,RATE ST SYSTEM BJ ED 435 TANK CAP C M GALLONS <36 NUMBER OF CO NTS IN THE UNIT u7 LYOL tU, M.TANK USE AND CONTENTS' TANK USE la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE iidude Used UT) ❑ 5.EMERGENCY GENERATOR FUEL ❑ 6.OTHER GENERATOR FUEL [RSC 4248I'3(cl1 ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 43% CONTENTS PETROLEUM: ❑ [_!:YM,ULAR UNLEADED O Ic.MI FUEL DE UNLEADED ❑ It.PREMIUM UNLEADED 440 LU-T. ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 440a NON-PETROLEUM:❑ 7.USED OIL ❑ I0.ETHANOL ❑ 11.OTHER NON-PETROLEUMS g40b TANK CONSTRUCTION TYPE OF TANK ❑ 1. CLE WALL .DOUBLE WALL ❑ 95.UNKNOWN 14a PRIMARY CONTAINMENT' .STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER❑ 7.STEEL+INTERNALE G ❑ 95.UNKNOWN ❑ 99,OTHER (S SECONDARY CONTAINMENT ❑ 1,STEEL .FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7,JACKETED❑ 90.NONE ❑ 95.UNKNOWN ❑99OTHER 5 OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SENT-OFF VALVE❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENTV. PRODUCT/WASTE PIPING CONSTRUCTIONPIPING CONSTRUCTION ❑1.S LE-WALLED .DOUBLE-WALLED ❑99OTHER SYSTEM TYPE .PRESSURE ❑2.GRAVCfY ❑ ;.CONVENTIONAL SUCTION ❑ 4.SAFESUC�ION 23 CCR§2636(a 3) 458 PRIMARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 8.FLEXIBLE 10.RIGID PLASTIC 'IM ❑ 90.NONE ❑ 9 OWN ❑ 99.OTf1ER(Specify): 4644 SECONDARY CONTAINMENT ❑ I.STEEL 4,FIBERGLASS ❑ FED ❑ IQ RIGID PLASTIC 464b ❑ 90.NONE ❑ OWN ❑ 99.OTIIBR(Spaify): 464c PIPING/I'URBIIYE CONTAINMENT SUMP TYPE I.SINGLE WALL ❑ 2.DOUBLE WAIL ❑ 90.NONE 4644 VL VENT,VAPOR RECOVERY(YR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL .FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464, VENT SECONDARY CONTAINMENT L464.1 S EL 4.FIBERGLASS 10.RIGID PLASTIC ,NONE 99.OTHER(Specify) 4641 VR PRIMARY CONTAINMENT .STEEL ❑ 4.FIBERGLASS *41171 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4INg VR SECONDARY CONTAINIr1ENT ,I&I ❑ 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99,OTHER(Specify) 469h VENT PIPING 7RANSfIION SIIMPTYPE er• 464h1 GLE W. - 2.DOUBLE WALL 90.NONE g6gi RISER PRIMARY CONTAINFIBNT 1.STEEL FIBERGLASS 10.RIGID PLASTIC 90.NONE 99,OTHER(Specify) 4641 RISER SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464k FILL COMPONENTS INSTALLED 464k1 .SPILL BUCKET 3.STRIKER PLATFIBOTTOM PROTECTOR CONTAINMENT SUMP 451&-c VII.UNDER DISPENSER CONTAINMENT:(Iiar l CONSTRUCTION TYPE .SINGLE WALL ❑ 2.DOUM-1 LE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 46% CONSTRUCTION MATE RfAL ,STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696, VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT .ISOLATION 448. IX APPLICANT SIGNATURE CERTWICATTON: I certify that this UST system is compatible with the b=rdoas substance stored and that the information provided herein is truq accunte, ud to fug Com Bance with legal requirements. APP A DATE 470. ''Amar/ APPLICANT NAME ) a` 471. APPLICANT 7fIL „r,� 4n. UPCF UST-B-1/2 ( ((/ Rev.(12/2007)