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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK 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 1,11,HI,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: °30a I DATE EXISTING UST DISCOVERED: r rV 4301, I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) I BUSINESS NAME(Same as C ITY NAME or DBA-Doing Business As) 3 1 4 Sl-f3-7 BUSINESSSITEADD SS iO3 CITY � [[ im L y cin. , C.fC�D� 11.TANK DESCRIPTION TANK ID* 432 TANK MANUFACTURER 433 TAM CONFIGURATION: THIS TANK IS 434 1.A STAND-ALONE TANK 2. ❑ ONE N A COMPARTMENTED MT. Ca tae one efora venom in theud�. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPAR MENTS IN THE UNIT 437 EaC M.T eNK USE.AND CONTENTS ,AN'K USE ❑ I..MOTORVEHICLE FUELING ❑ Ib.b1ARINA EUELMG ❑ Ic.AVIATION FUELING 439 103.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Indus®Used Oil ❑ 5.EMERGENCY GENERATOR FUEL[HSC ❑ 6.OTHER GENERATORFUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439. CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 - - ❑ 3.DIESEL ❑5.JET FUEL - -- ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL 9.OTHER PETROLEUM (Specify): N1 >r o 44m NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4401, IV. TANK CONSTRUCTION TYPE OF TANK 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ I.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LMNG ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444. SECONDARY CONTAINMENT ❑ 1.STEEL El 3.FIBERGLASS ❑ 6.MERIORMEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER(5 eci ): 445a .A OVERFILL PREVENTION ❑ 1. UDIBLE&VISUAL ALARMS ❑ 2.BALL 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 M.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458 PRIMARY CONTAINN,!ENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ &FLEXIBLE ❑ 10.RIGID PLASTIC 46 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Spec[fy): 464a SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 469c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 961d VI.VENT,VAPOR RECOVERY(VR)AND'RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT Ll L STEEL LJ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4Mf 464ft VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464g 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS IO.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 46941 VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464i. RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 4Rk 464k1 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTON PROTECTOR ❑ 4.CONTAINMENT SUMP 451., VII.UNDER DISPENSER CONTAINMENT(UDC) I CONSTRUCTION TYPE ❑ I SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.':O DISPENSERS ❑ 90.NONE 464' CONSTRUCTION MATERIAL ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696, VIIL CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 443. IX. 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 APPLICANT NAME(print) 471' APPLICANT TITLE 672' UPCF UST-B-I/2 Rev.(12/2007)