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• • T) cyj UNIFIED PROGRAM CONSOLIDATED FORM t 216 UNDERGROUND STORAGE TANK O 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 45DI.NEW PERMIT C] 3.C16.TEMPORARY UST CLOSURE ❑ 7.UST PWAL PERMIT 5 OF FORMATION PERMANENT CLOSURE ON SITE E] 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 41- DATE EXISTING UST DISCOVERED: iLp 4306 I. FACILITY INFORMATION 1 FACILITY ID#(Agency Use Only) - - BUSINESS NAME LStainne as FACILITY NAME or DBA-Doing Business As) 3 I be 4t BUSINESS SITE ADDRE 103 CITY �>Z / L l04 he- C II.TANK DESCRIPTION TANK ID 9 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK Is 434 ��ss .A STAND-ALONE TANK ILP67, 6 ❑2.pl ONE NA COMPARTMENTED UNIT r'f Com aeone for MP RT an D ffie UNIT. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY N GALLONS 436 NUMBER OF COMPARTMENTS N THE UNIT 437 I M.TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ 16.iv1ARNA FUELING ❑ ic.AV Lv LION FUELING .19 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(ncmda Used On) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25291.5(c)] ❑ 6.OTHER GENERATORFUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ [a.REGULAR UNLEADED ❑ IL.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL - ❑ 5./ET FUEL- - E36.AVIATION G - _ - ❑ S.PETROLEUM BLEND FUEL 9.OTHER PETROLEUM (S(Specify): AS G 1>f MOn NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 06 ❑ II.OTHER NON-PETROLEUM(S eci ): W. TANK CONSTRUCTION TYPE OF TANK 11.SINGLE WALL ❑ 2.DOUBLE WALL C3 95.UNKNOWN - ata PRIMARY CONTAINMENT ❑ LSTEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S ee' ): 444a SECONDARY CONTAINMENT ❑ I.STEEL ❑3.FIBERGLASS ❑ P. EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.[1NKNOWN ❑99.OTHER(Speci ): 445a OVERFILL PREVENTION ❑ I.AUDIBLE&VISUALALARMS 2.BALLFLOAT ❑ 3.FILLL TUBE SHUT-OFF VALVE 452 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPINGCONSTRUCTION '^I.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ❑ I.PRESSURE C12.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR¢2636(x)(1)) 459 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ ..FIBERGLASS ❑ 8.FLEXIBLE ❑ I0.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ B.FLEXIBLE ❑ 10.RIGID PLASTIC 46x6 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 46Mc PIPNGTURBNE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d AT.VENT,VAPOR:RECOVERY(VR)AND TER/FILL PIPE PIPING CONSTRUCTION - - VENT PRIMARY'CONTAINMENT I.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC U90.NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ 1. c,c, ❑ 4.FIBERGLASS El 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER 461E 464PI VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FBJERGL _SS ❑ lO.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 44 64,1 VR SECONDARY CONTANMENT ❑ L STEEL n 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 461h 464hi VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464'. RISER PRIMARY CONTANMENI ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4464%1 RISER SECONDARY CONTAINMENT C] L STEEL ❑ 4.FIBERGLASS I0.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464h 46 k1 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET J.STRIKER PLAT&BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451ac VII.UNDER DISPENSER CONTAINMENT(UDC) n n -ryog I ^!GL :".LL [D 2.DOUBLE WALL El 3.NO D1SP-NSLR5 C1 90.NONE n6s. C_NSTRCT C ❑ CONSTRUUCTION MATERIAL ❑ 1 STEEL [1 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696 VIII. CORROSION:PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 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. 4t0. APPLICANT SIGNATURE DATE APPLICANTTITLE 4n. 471. APPLICANT NAME(print) UPCF UST-B-1/2 Rev.(12/2007)