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9 I i `� - ry UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one fmm T) TYPE OF ACT1ON (Check one item only. Foran UST permanent closme or removal,complete only this affiectsoCn sed Sections S 4 Ill,IV,and below) 430 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT f- 5.CHANGE OF INFORMATION 6,TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4JO° DATE EXISTING UST DISCOVERED: 430t, I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 9 _ 1 i BUSINESS NAME(Same as FACILITY N m DBA-Doing Busipa}C 3 M .� fv c� kb �C. BUSINESS SITE ADDRESS�1f W c-)3 a M/7f-- 1/)./ CITY ^ ►`-� CA . IN K IL'TANDESCRIPTION/V TANK ID# 432 TANK MANUFACTURER 433 TA OND(RIRATION:TVs TANK IS 434 I R D J I� �/�, .n... ).A STAND-ALONE TANK �YJ/V .,( r(�jv/x-� "`l ❑2.ONE MACOMPARTMENTED m DATE UST SYSTEM INSTALLED 435 TANK APACITY INGALLONS 434 NUMBER OF COMPARTMENTS INTHE UNIT 433 7 C> III.TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ It.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(lecluda Used Ol0 ❑ 5.EMERGENCY GENERATOR FUEL ❑ 6.OTHER GENERATD FUEL ❑ 95.UNKNOWN ❑ 99 OTHER S RISC 423251.5(c)] CONTENTS PETROLEUM: la REGULAR UNLEADED (specify): 4394 ❑ 1c.MIDGRADE UNLEADED ❑ 19.PREMIUM UNLEADED 3% [13.DIESEL ❑ 5.IEC FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL [19.OTHER PETROLEUM S 440. NON-PETROLEUM:[1 7.USED OIL ❑ 10.ETHANOL El 11.OTHER NON-PETROLEUMS 410b TANK.CONSTRUCTION TYPEOFTANK 0.SINGLE WALL ET 4U0 WALL Ll 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL kr3.FIBERGLASS ❑ 6.INTERNAL BLADDER µ ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (specify), 444a SECONDARY CONTAINMENT ❑ 1.STEEL Ell.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER *15 ❑ 90. ONE ❑ 95.UNKNOWN ❑99.OTHER(S ): ❑ 7.JACKETED 1454 OVERFILL PREVENTION .AUDILE A VISUAL ALARMS .BALL FLOAT 3.FILL TUBE SHUTOFF VALVE 452 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPAIG CONSTRUCTION ❑I. GTL-WALLED 01DOUBLE-WALLED ❑99. TTHER 460 SYSTEM TYPE LF1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION El 4.SAFE SUCTION 23 CCR 120640 4511 PRIMARY CONTAINMENT I.STEEL �[}' .FBERCLASS ❑ S.FLEXBI.E ❑ 10.RIGS PLASTIC 96a ❑ 90.NON; 1195.UNKNOWN ❑ 99.OTHER(Specify): 464 SECONDARY CONTAINMENT El 1.STEEL 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4616 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(SpMfy): 969e PIPINGRURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLEWALL 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464 461e1 VENT SECONDARY CONTAINMENT 0 1.STEEL -Er 4.FIBERGLASS E3 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) Wf WE VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 4645 VR SECONDARY CONTAINMENT Ll 1.STEEL XFf FIBERGLASS 10.RIGID) 464.1 PLASTIC 90.NONE 99.OTHER(Specify) 4646 469h1 VENT PIPING TRANSITION SI/MP TYPE 1.SINGLE WALL 2.DOUBLE WALL W.NONE 464i RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS UR 10.RIGID PLASTIC US 90.NONE Ll 99.OTHER(Specify) 460 96'1 RISER SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 46/k "I FILL COMPONENTS INSTALLED lkf SPILL BUCKET .STRIKER PLATEBOTTOM PROTECTOR 4.CONTAINMENT SUMP 451st VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WAIL J21.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ W.NONE 46A CONSTRUCTION MATERIAL ❑ 1.STEEL .FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(S i ) 4696c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 416. IX. APPLICANT SIGNATURE CERTQ+ICATION: I certift that this UST system is compatible with the hazardous substance stored and that the mfosmation provided herein is true,accurate, and!01,11 complionqs,with legal requirements. APPLICANT SIGNATU /y � DATEL( �7 / H - 420 APPLICANT NAME Onint) (• 471' APPLICANT TITLE 4n UPCF UST-B-1/2 Rev.(122007)