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IED PROGRAM CONSOLIDATED FOR <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) <br /> I% <br /> OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11,111,IV,and IX below) a3o, <br /> [g 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ S.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 439.. DATE EXISTING UST DISCOVERED: 4306. <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) _ _ 1 1 <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) lG 3. <br /> MANNTCCA kwcK <br /> BUSINESS SITE ADDRESSl03 <br /> 8" � � yocifratl /�)L . � crry oa. <br /> KANTrCA I OA H'I'S3_Y <br /> II. TANK DESCRIPTION <br /> TANK ID H Q6 432 TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434 <br /> ❑ 1,A STAND-ALONE TANK Complete one page for each <br /> [V2 ONE IN A COMPARTMENTED UNIT companment in the unit. <br /> DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436_ NUMBER OF COMPARTMENTS IN THE UNIT 437 <br /> (, ©©O I <br /> III. TANK USE AND CONTENTS <br /> TANK USE la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING 0 lc.AVIATION FUELING 439. <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oi0 ❑ 5.EMERGENCY GENERATOR FUEL IHSC§25281.5(.)] <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99. THER(Specify): 439.. <br /> _ ........_..... <br /> CONTENTS PETROLEUM: ElUNLEA <br /> Ia.REGULAR UNLEADED ❑ Ic.MJOG RADE DED U111b.PREMIUM UNLEADED 440- <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440a, <br /> ............ __.- -. _______ .-....-.-.-.-._...-.-.--.-....... <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ I0.ETHANOL <br /> ❑ I I.OTHER NON-PETROLEUM(Specify) 4466. <br /> IV TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 <br /> PRIMARY CONTAINMENT 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 440 <br /> 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify) 444a <br /> .-.-.-.. __' .__..... NE LINE__ ............. ........4-4-5_._ <br /> SECONDARY CONTAINMENT � I.STEEL ❑3.FIBERGLASS ❑ 6 EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 4°5 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445.. <br /> OVERFILL PREVENTION ❑ I.AUDIBLE&VISUAL ALARMS ❑ 2 BALL FLOAT IN 3.FILL TUBE SHUT-OFF VALVE °5z <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT /WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 99.OTHER 460. <br /> _- __ _ .. I...... ___._. A-_F'..____________________________________ <br /> SYSTEM TYPE �I PRESSURE ❑ 2 GRAVITY ❑ 3 CONVENTIONAL SUCTION ❑ 4 SAFE SUCTION)23 CCR§2636(a)D)] _----_458_..___. .-_ .__-. ._ <br /> PRIMARY CONTAINMENT [II.STEEL D�A.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 0b6. <br /> -_ ____________ --._. ..-_.-.-.-_ ________- - -....-_______ ______.-. ...____ ..........._......alb__ <br /> SECONDARY CONTAINMENT ❑ I.STEEL 4 FIBERGLASS ❑ 8 FLEXIBLE ❑ 10.RIGID PLASTIC <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464.. <br /> PIPINGIT URBINE CONTAINMENT SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE <br /> VI. VENT,VAPOR RECOVERY (VR) AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ I.STEEL 0L 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4464581 <br /> ................ -._-.-._- ......-________ ..-.-.-. .-.---.____- _.__._-_.. _.-------.. ...._-._- __-__________.._.___ 454F.- <br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4 FIBERGLASS ❑ to RIGID PLASTIC %90.NONE ❑ 99.OTHER(Specify): 464f1 <br /> .......... .......... ............... _...-..._..---------_ -. __---..-__ _..._______ _. _--- -.-..-__.--. ._____._______._.__ _ a3a-_. <br /> VR PRIMARY CONTAINMENT ❑ I STEEL �a FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90.NONE ❑ 99 OTHER(Specify): 464$8_ <br /> _.._----_____----__ .............. ...... -..-....-.-.-.- __________._________ ............. ...... . ._______ <br /> VR SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4 FIBERGLASS ❑ 10.RIGID PLASTIC % 90.NONE ❑ 99.OTHER(Specify): 464h. <br /> W a fY)� 464h1. <br /> ..__- -_ _ <br /> VENT PIPING TRANSITION SUMP TYPE ❑ I SINGLE WALL ❑ 2.DOUBLE WALL 90 NONE <br /> RISER PRIMARY CONTAINMENT AL STEEL ❑ 4 FIBERGLASS [1 10.RIGID PLASTIC [1 90.NONE C199.OTHER(Specify) 464j <br /> ...................... ................_-.__-_-- ..._...-. . .. .._--...._.- .-.-.- .............._________._._. <br /> RISER SECONDARY CONTAINMENT ❑ ].STEEL ❑ 4 FIBERGLASS ❑ 10 RIGID PLASTIC X 90.NONE ❑ 99.OTHER(Specify): -4.6-4k.-I--- <br /> TI <br /> 6641 <br /> __ ___--. ________ __ ._........_______ _ __ _ .. - ---...____________ _ ........­----------- <br /> ---_ .. <br /> FILL COMPONENTS INSTALLED I.SPILL BUCKET 3 STRIKER PLA MOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 456-c. <br /> VII. UNDER DISPENSER CONTAINMENT (UDC) <br /> CONSTRUCTION TYPE QQ-I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NOIW,_-} 469.. <br /> ....... .......-......... ....-....--- .-.-'--'" ---"_............_.-._.._-...._.."' aoT�. 'a 469b. <br /> CONSTRUCTION MATERIAL ❑ 1 STEEL 4 FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 99 OTHER(Specify) 469.. <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2,SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 449. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, <br /> accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE72 <br /> 170- <br /> APPLICANT NAME(print) 4°I' APPLICAN TITLE ""' 472. <br /> UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org <br />