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i UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(on f r per 7 TYPE OF ACTION (Check one item only. Fora T permanent closure or removal,complete only this section and Sections 1,11,111,IV,and IX below) 430 I.NEW PERMIT 3.RENEWAL PERMIT ❑ 5.CI1 ��14� �AL HEALTH 6.TEMPORARY UST CLOSURE F-17.UST PERMANENT CLOSURE ON SITE ❑ 8.0 REM A DATE UST PERMANENTLY CLOSED. 4"a 1 DATE EXISTING UST DISCOVERED: - . RTM E N T 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 BUSINES T DD 103 CITY 104 AY, = T II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 ' .A STAND-ALONE TANK 2.ONIE IN A COMPARTMENTED UNIT. Complete one page for each wmpwtimni in the uniL DATE UST S3TEM INSTALLED 435 TA CAPACITYIN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 �� ao 00 M.tANK USE AND CONTENTS TANK USE [:�,la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ElIc.AVIATION FUELING 439 (� 3.CHEMICAL PRODUCT STORAGE ❑4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC 125281 S(e)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 434+ CONTENTS PETROLEUM: a.REGULAR UNLEADED C1Ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 �.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440,1 NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL W7.DOUBLEWALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ I.STEEL 3JI.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE 0 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS [12.BALL FLOAT PD.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 M.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(x)(3)] 458 PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464u SECONDARY CONTAINMENT ❑ 1.STEEL (C4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURB[NE CONTAINMENT SUMP TYPE ❑ I.SINGLE WALL .DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464c 464c1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 10.RIGIDPLASTIC 0 90.NONE 0 99.OTHER(Specify) 464r ,1641 VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464g] VR SECONDARY CONTAINMENT ❑ 1.STEEL Ej 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE I.SINGLE WALL .DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT1.STEEL [14.FIBERGLASS El 10.RIGID PLASTIC [I90.NONE ❑ 99.OTHER(Specify) 4641 464'1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL EY4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED L SPILL BUCKET .STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 451a< VII.UNDER)DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ I.SINGLE WALL ajo.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ L STEEL .FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b- VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) [14.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, -ang in full compliance with legal requirements. APPLICANT SIGNATU DATE 4i0. APPLICANT NAME(print) /� 471' APPLICANT TITL 472' UPCF UST-B-1/2 Rev.(12/2007)