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00q 0471' �-� UNIFIED PROGRAM CONSOLIDATED FORM ` UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) 430 P TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this sectio5n NGE OFand Sections ,INFORMATION below) ❑ 1.NEW PERMIT C33.RENEWAL ERMIT C] ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE El 8.UST REMOVAL 430b DATE UST PERMANENTLY CLOSED: DATE EXISTING UST DISCOVERED: I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) G - - 3 BUSINESS NA E(Same as FACILITY NAME or DBA-Doing Busin As) c L B S S� loa Or to CI � U II.TANK DESCRIPTION TANK ID# 43'- TANK MANUFACTURER 433 FT CONFIGURATION: THIS TANK IS434 1.A STAND-ALONE TANK ONE IN A COMPARTMENTED UNIT. Com tete one a for each com amnent in the.- DATE hewriDATE UST SYSTEM INSTALLED 435 ACITY IN GALLONS 436 NUMBERCOMPARTMENTS IN THE UNIT 437 cv III.TANK USE AND CONTENTS TANK USE *la.MOTOR VEHICLE FUELING C] lb.MARINA FUELING ❑ lc.AVIATION FUELING 439 *3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] 439a 6OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS 440a ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S i : e- NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 440b 11.OTHER NON-PETROLEUM(Specify): IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT C] 1.STEEL Ll3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S i ): 444a SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify)' 445a OVERFILL PREVENTION I.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 ❑2.DOUBLE-WALLED ❑99.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 ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99,OTHER(Specify): 464d PIPINGITURBtNE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL [32.DOUBLE WALL C] 90.NONE VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT Lj 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464g] VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASC! 90.NONE 99.OTHER(Specify) 464n TIC 464h VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 464'• RISER PRIMARY CONTAINMENT ❑ L STEEL Lj 4.FIBERGLASS C] 10.RIGID PLASTIC LJ 9u NONE 99.OTHER(Specify) 4641 464'1 RISER SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464k 464k1 FILL COMPONENT'INSTALLED ❑ L SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR U 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b` VIII. CORROSION PROTECTION aas. STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 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 an. APPLICANT NAME(print) alt. APPLICANT TITLE UPCF UST-B-1/2 Rev.(12/2007)