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UNIFIED PROGRAM CONSOLIDATED FORM W430 UNDERGROUNDSTORAGETANKPEOPERATING PERMIT APPLICATION-TANK INFORMATION(One formper UST)TYOFACTION (Check one item only. For an UST permanent closureor removal,complete only this section and Sections I,II,ltl,IV,and IX below) ® 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL 4306 DATE UST PERMANENTLY CLOSED: 4301 I DATE EXISTING UST DISCOVERED: I. FACILITY INFORMATION FACILITY ID N(Agency Use Only) - F1 1 - 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 Rvc old q1qf $ GI Ud Z- 104 BUSINESS SITE ADDRESS 103 1TY m�N'E ZO � B MlC G II.TANK DESCRIPTION TANKID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 ANIC Tg 05009 r � C/ �^GJ �.ASTANTYAIANETTME ONE INA COMPARTMENTED to unit.Co deone fm mcb wm orcin Neunil. DATE UST SYSTEM INSTALLE TANK CAPACITY IN GALLONS 636 NUMBER OF COMPARTMENTS IN THE UN434 0 m R '� y-o oITIT r4taN in.TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING El Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 �3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Ihelu Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(,)] [16.OTHER GENERATOR FUEL [195.UNKNOWN [199.OTHER(Specify): 439' CONTENTS PETROLEUM: 'z!�,Ia.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ It.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ S.JET FUEL ❑ &AVIATION GAS a90a ❑ &PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (specify): NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL Wb ❑ II.OTHER MON-PETROLEUMS i IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTER AL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444' SECONDARY CONTAINMENT ❑ 1.STEEL FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE W. UNKNOWN ❑99.OTHER S ): 445' OVERFILL PREVENTION ❑ I.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMEMSFOR EXEMPTION FROM OVE L REVEMION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑L SINGLE-WALLED .DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE AZI4,PRESSURE Lj 0.4. 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION [14.SAFE SUCTION 123 CCR§2636(.X3)1458 PRIMARY CONTAINMENT ❑ f 1.STEEL �AFIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464' SECONDARY CONTAINMENT ❑ I.STEEL 42k4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464, PIPING/TURBINE CONTAINMENT SUMP TYPE L SINGLE WALL AL2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL �4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0.NONE ❑ 99.OTHER(Specify) 464f 464Fl VR PRIMARY CONTAINMENT ❑ LSTEEL T�FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464g 4M 1 VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 5RjZ0.NONE ❑ 99.OTHER(Specify) 4646 a64m VENT PIPING TRANSITION SUMP TYPE 'S"! 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 464.. RISER PRIMARY CONTAINMENT L STEEL ❑ 4.FIBERGLASS U 10.RIGID PLASTIC ❑ 9U.NONE 99.OTHER(Specify) 4641 464'1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC JZ,,90.NONE U 99.OTHER(Specify) 4644 4Mk1 FILL COMPONENTS INSTALLED .SPILL BUCKET ❑ 3.S HCERPLATE/BOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469' CONSTRUCTION MATERIAL ❑ 1.STEEL [14.FIBERGLASS 10.RIGID PLASTIC ❑ 99.01HER(Specify) 4696, VIII. CORROSION PROTECTION a STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATIONc`- DC. APPLICANT SIGNATURE .� CERTIFICATION: I certify that this UST system is compatible with the hacardous substance stored and that the information pro 5, herein is true,accurate, and in fat com fiance with 1 al requirements. / /O 470. APPLICANT SIGNATURE DATE C..:1)O L PLICANT NAME t) N 471. APPLICANT TITLE 4rz V IcE - PR&s NT UPCF UST-B-1/2 Rev.(1712007)