BILLING - Laserfiche WebLink

Home Browse Search

a Of IFIED PROGRAM CONSOLIDATED F �f UNDERGROUND STORAGE TANK V� ��') r 17-11 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,11,III,IV,and IX below) 430 Qg. 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: 430. DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ _ C D 1 BUSINES NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 tw.oc Sk (�xx Ll (_ BUSINESS SITE ADDRESS "' 103 SopS k ... a. �J CITY cea ', Ia II.TANK DESCRIPTION TANK ID# �/7!"�/Q��j/ 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 W rrs4i & I.A STAND-ALONE TANK C CSS ❑2.ONE IN A COMPARTMENTED UNIT. F Com let-one pg.for a co tat in the vert. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMB R OF COMPARTMENTS IN THE UNIT 437 tillI III.TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc.AVIATION FUELING 439 O 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Ind.d.USM OH) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)) O 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ® 99.OTHER (Specify): a tCV ( 439e CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ 1b.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS C18.PETROLEUM BLEND FUEL 9.OTHER PETROLEUM (S ci : � cc.4\-.L :\ 440e NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL JR 11.OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION TYPE OFTANK $ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT X 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444. SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS O 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE O 95.UNKNOWN 99.OTIBR(Specify): i 'k bcsyt 445. OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TU E SHUT- VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 1.SINGLE-WALLED O 2.DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR§26360)(3)] 458 PRIMARY CONTAINMENT I.STEEL O 4.FIBERGLASS 0 8.FLEXIBLE I] 10.RIGID PLASTIC 464 ❑ 90.NONE O 95.UNKNOWN ❑ 99. (Specify): 464. SECONDARY CONTAINMENT [11.STEEL ❑ 4.FIBERGLASS O 8.FL}D(IBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN 51 99.OTHER(Specify): C. ' 464e PIPING/TURBINE CONTAINMENT SUMP TYPE [J1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS O 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify) 464, 464el VENT SECONDARY CONTAINMENT ❑ L STEEL O 4.FIBERGLASS ❑ 10.RIGID PLASTIC I@ 90.NONE ❑ 99.OTHER(Specify) 464f 46411 VR PRIMARY CONTAINMENT ❑ 1.STEEL O 4.FIBERGLASS ❑ 10.RIGID PLASTIC '® 90.NONE ❑ 99.OTHER(Specify) 464, 4M,I VR SECONDARY CONTAINMENT ❑ 1.STEEL D 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE O 99.OTHER(Specify) 464b VENT PIPING TRANSITION SUMP TYPE 46441 � 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS O 10.RIGID PLASTIC 2S 90.NONE Cl 99.OTHER(Specify) 464j RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC -19464'1 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATEIBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451.< VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL3.NO DISPENSERS C190.NONE 469. CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 9 L.OTHER(Specify) 4696s VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT448. .Pg 6.ISOLATION IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stared and that the information provided herein is true,accurate, and in full compliance with legal requirements. APPLIC SIGNATUREqi -1 E _ 470. DAT s� APPLICANT kME(print) 471. APPLICANT T LE 472. UPCF UST-B-V2 Rev.(12/2007)