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UNIFIED PROGRAM CONSOLIDATED FORM l►�0(��' UNDERGROUND STORAGE TANK ` �1 OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) 430 TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE [18.UST REMOVAL 430b DATE UST PERMANENTLY CLOSED: DATE EXISTING UST DISCOVERED: I FACILITY ID#(Agency Use Only) I. FACILITY INFORMATION- 3 BUSINESS AME Same as FACILITY AME or DBA- oingaBusines104 BUS SD1�S -71 UJ 03 CI. DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 CONFIGURATION:THIS TANK IS 434 .A STANDALONE TANK �(J 1 [12.ONE IN A COMPARTMENTED UNIT. complete one page for each com anmefn in the unit DATE U SYSTEM INSTALLED 435 T APACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 Lv 1 III.TANK USE AND CONTENTS TANK USE *Oa.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc.AVIATION FUELING 439 CHEMICAL PRODUCT STORAGE [14.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§2528I.5(c)] 439a .OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 440 CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.A TON WS440a [-18.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): V NOut N-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 440b 11.OTHER NON-PETROLEUM(Specify): IV. TANK CONSTRUCTION 443 TYPE OF TANK [11.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 444 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER [17.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 445a 90.NONE [195.UNKNOWN [199.OTHER(Specify): OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 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 ❑1.SINGLE-WALLED [12.DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ I0.RIGID PLASTIC 464b 464c C390.NONE ❑ 95.UNKNOWN [199.OTHER(Specify): PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL El 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ L STEEL [3 4.FIBERGLASS ❑ 10.RIGID PLASTIC [190.NONE ❑ 99.OTHER(Specify) 464f 4644 VR PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.N ❑ 99.OTHER(Specify) 464s 464 l VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NO4641. NE RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE El 99. (Specify) 4643 464'I RISER SECONDARY CONTAINMENT ❑ L STEEL [14.FIBERGLASS [1 ]0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4644 46441 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS [1469a 90.NONE 469 9a CONSTRUCTION MATERIAL ❑ 1.STEEL [714.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 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 full compliance with legal requirements. 470. APPLICANT SIGNATURE DATE rAWPLICANT a7z. a71. APPLICANT TITLENAME(print) UPCF UST-B=1/2 Rev.(12/2007)