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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. For an US crmancnl closure or removal,complete only this section and Sections 1,11,III,IV,and IX below) 430 1.NEW PERMIT RENEWAL PERMIT [15.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4304 DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ I BUSINESS NAME(Same as FALI NAME D AAess As)CI � 3 a262 7-9 BUSINESS SITE ADD�tESS `^ - Q 101 CITY 104 3 (( 1V d II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 414 ❑1.A STAND-ALONE TANK [WONE IN A COMPARTMENTED UNIT. Com Icic one page for each compartnmt in the unit. DATE UST SYSTEM INSTALLED 435 TNNK CAP IN GALLONS 436 NUMBER OF C PARTMENTS IN THE UNIT 437 III.fANIC USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ 1 c.AVIATION FUELING 439 (] 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL 1HSC§25281.5(.)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Spedfy): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ ]b.PREMIUM UNLEADED 440 $L3.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 TYPE OF TANK ❑ L SINGLE WALL IM2.DOUBLFWALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1-STEEL fir 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ I.STEELFIBERGLASS ❑6.EXTERIOR MEMBRANE LINER [17.JACKETED 445 ❑ 90.NONE [95.UNKNOWN ❑99.OTHER(Specify): 4454 OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT I E 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 W.DOUBLE-WALLED [199.OTHER460 SYSTEM TYPE PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 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 ❑ 1.STEEL �4.FIBERGLASS ❑ 8.FLEXIBLE Ll 10.RIGID PLASTIC 4646 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464. PIPINGIfURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL _DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ L STEEL4.FIBERGLASS 0 10.RIGIDPLASTIC ❑ 90.NONE Ej 99.OTHER(Specify) 464c 464cl VENT SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 464(1 VR PRIMARY CONTAINMENT ❑ L STEEL X4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90_NONE ❑ 99.OTHER(Specify) 464g 464 1 VR SECONDARY CONTAINMENT ❑ L STEEL .FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464, 464h1 VENT PIPING TRANSITION SUMP TYPE I.SINGLE WALL ne.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 464'I RISER SECONDARY CONTAINMENT ❑ 1.STEEL R4.FIBERGLASS 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED dLLSPILLBUCKET gr 3.STRIKER PLATE/BOTTOM PROTECTOR W,4.CONTAINMENT SUMP 45la-c VIL UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL .DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL RL4.FIBERGLASS 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696-. 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 com 1 nce with legal requirements. ago. APPLICANT SIGNATURE DATE /O APPLICANT NAME r- 471. APPLICANT TITLE 472' UPCF UST-B-1/2 Rev.(12/2007)