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0 R UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK FEB 14 2014 OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) T E OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II, b 1.NEW PERMIT ® 3.RENEWAL PERMIT El5.CHANGE OF INF EffrAL [:16.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DEPARTMENT DATE UST PERMANENTLY CLOSED: "c' DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as F CILITY NAME or DBA-Doing Business As 3 T+; S F V BUSINESS SITE ADD SS c� 103 2 UJM) k�L`. CITY M+,N\ 1 r C-PI5 (e l04 II.TANK DESCRIPTION TANK ID# O O 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 U V❑�1.A STAND-ALONE TANK K2.ONE IN A COMPARTMENTED UNIT. Comlete ane Ibreach cam mt in the wit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY6 N IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 � v III.TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL(HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 43% CONTENTS PETROLEUM: CI In.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): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPEOFTANK ❑ LSINGLEWALL 2.DOUBLEWALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT 1.STEEL [13.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER [17.JACKETED 445 ❑ 90 .NONE ❑ 95.UNKNOWN ❑99.OTHERS eci 445a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS LJ 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 L SINGLE-WALLED 2.DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION In CCK§2636(a 3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4Ma SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Spedfy): 464. PIPINGfIURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4Md VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I.STEEL P9,4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464e) VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT ❑ I.STEEL K 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 4M,I VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464h 4Mb1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL [3 2.DOUBLE WALL IS 90.NONE 4641. RISER PRIMARY CONTAINMENT 15 1.STEEL ❑ 4.FIB_E_RG_L_A_S_S___0 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 464j 464 1 RISER SECONDARY CONTAINMENT E] 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED IL 1.SPILL BUCKET IQ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469. CONSTRUCTION MATERIAL ❑ L STEEL gL4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 16.6.ISOLATION 448. 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 fullcombliance with al requirements. APPLICANT SIGNATURE DATE /Lit 470. - / - APPLICANT NAME ' t v '^ t 4^ 471. APPLICANT TITLE k e Y 47z. UPCF UST-B-1/2 I` •( Rev.(12/2007)