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UNIFIED PROGRAM CONSOLIDATED FORM if Z/ ©� UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closum or removal,complete only this section and Sections I,H,111,IV,and IX below) On 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 PERMANENTLYCLOSED: °10i DATE EXISTING UST DISCOVERED: a 4301, !/ 2 r� I. FACILITY INFORMATION FACILITY ID N(Agency Use Only) 1 BUSINESS NAME Same as FACILITY NAME or DBA-Doing Business As) 3 J r, BUS SSITE ADDRE 193 CITY L 1oa Wee,4 II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 rANK'ONFIcuRAnoN: THIS TANK Is 43a STAND-ALONE TANK ( ❑2.ONE IN A COMPARTMENTED UNIT. Im ane fvch mtmtl�eumc DATE UST SYSTEM INSTAL ED 435 TANK CAP IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UMT 4n III.TANK USE AND CONTENTS TANK USE ❑ fa.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIA7IONFUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(hMu4v Ux Din ❑ 5.EMERGENCY GENERATOR FUEL(HSC M2S2813(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(S ify): 43% CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ S.JET FUEL ❑ 6.AV WTION AS t ❑ S.PETROLEUM BLEND FUEL 9.OTHER PETROLEUM NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUMS i ): 4306 IV. TANKCONSTRUCTION TYPE OF TANK 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN PRIMARY CONTAINMENT 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER S 444. SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LMER ❑ 7.1ACKECED 445 17190.NONE ❑ 95.UNKNOWN E399.OTHER S 445.5 OVERFILL PREVENTION ❑ I.AUD®LE&VISUAL ALARMS Ll 2.BALL FLOAT - 3.FILL TUBE SHUTOFF VALVE 452 [14.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED [12.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ❑ LPRESSURE ❑ 2.GRAVDY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR 12636(a)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL Ll 4.FIBERGLASS 138.FLEXIBLE ❑ 10.RIGID PLASTIC 464 C190.NONE ❑ 95.UNKNOWN [399.OTHER(Specily): 464 SECONDARY CONTAINMENT C31.STEEL ❑ 4.FIBERGLASS ❑ &FLEXIBLE ❑ 10.RIGID PLASTIC 4641 [190.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): a64 PIPINGfrURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE ALL ❑ 2.DOUBLE WALL 90.NO4644 VI'.VENT,VAPOR RECOVERY(VR)AND RISER/FEL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464 VENT SECONDARY COMAMMEM I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4464f VR PRI1ABY CONTAINMENT 46an ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464g VR SECONDARY COMAMh1EM 464 1 ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGm PLASTIC ❑ 90.NONE 99.OTHER ISpxify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS I0.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464j 4M'I RISER SECONDARY COMANMEM L STEEL 4.FIBERGLASS f0.RIGA PLASTIC 90.NONE 99.OTHER ISperify) 464k FILL COMPONENTS INSTALLED L SPILL BUCKET 3.STRIKER PLATFtBOTrOM PROTECTOR 4.CONMNMENT SUMP a�Kl VII:UNDERDISPENSER CONTAINMENT(UDC), CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOIJBI�WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469+ CONSTRUCTION MATERIA. ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGm PLASTIC ❑ 99.OTHER(Specify) 4696c VIIL CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION Me. UL APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full compliance with legal requirements. APPLICANT SIGNATURE DATE 470. APPLICANT NAME(print) 471' APPLICANT TITLE 4n. DPCF UST-B-1/2 Rev.(1212007)