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IFIED PROGRAM CONSOLIDATED F 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 1,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 DATE EXISTING UST DISCOVERED: 4301, I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ _ I i ! O I BUSINESAME(Sa Nme as FACIL TY NAME or DBA-Doing Business As) C 3 xx LI.L BUSINESS SITEADDRESS ^ ` 103 CITY IN II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 1.A STAND-ALONE TANK 2.ONE IN A COMPARTMENTED UNIT. Complete one Me for each wmartmat ia the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 20 � M.TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ le.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Iadudes Used Oil) ❑ 5.EMERGENCY GENERSATOR FUEL IHSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN 1$ 99.OTHER (Specify) F 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ le.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL 9.OTHER PETROLEUM IS ify): tl. 440a NON-PETROLEUM:❑ 7.USED OIL ❑ I0.ETHANOL A�� 1 4406 IV. TANK CON TRUCTION TYPE OF TANK 19 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT lK 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL [13.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JA KETED 445 ❑ 90.NONE ❑ 95.UNKNOWN 99.OTHER(Specify): s..+•.3t' 445a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALLFLOAT ❑ 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.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTTON 123 CCR§2636(a(3)I 458 PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLAS C 4646 ❑ 90.NONE ❑ 95.UNKNOWN 01 99.OTHER(Specify): yt,p.w� 464c N PIPINGIRBINE CONTAINMENT SUMP TYPE El 1.SINGLE WALL LI 2.DOUBLE WALL w ❑ 90.NONE , 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC PX 90.NONE ❑ 99.OTHER(Specify) 464e 464.1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 14 90.NONE ❑ 99.OTHER(Specify) 464F 46411 VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC '® 90.NONE ❑ 99.OTHER(Specify) 4648 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL [1 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464h 4Mh1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 464i. RISER PRIMARY CONTAINMENT E] 1.STEEL ❑ 4.FIBERGLASS ❑ 10LA .RIGID PSTIC 9ll NONE ❑ 99.OTHER(Specify) 4641 4641 RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC IR 90.NONE ❑ 99.OTHER(Specify) l64k 464k1 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATF/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451st VII.UNDER DISPENSER CONTAINMENT(UDC) C= CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL JR 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL [1 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) C4696 VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION DC. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hamrdous substance stored and that the information provided herein is true, curate, and in full com liance with legal requirements. APPLI SIGNATURE DATE t 470. S 1} APPLICAN NAME(pnnt) II 47I. APPLI4ST Tf � ( 472. [1 kCc 5 sum UPCF UST-B-1/2 Rev.(12/2007)