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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 UST permanent closure or removal,complete only this section and Sections I,II,III,IV,and Il below) 430 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 43oa DATE EXISTING UST DISCOVERED: 430b I FACILITY INFORMATION FACILITY ID#(Agency Use Only) t BUSINESS NAME a�e as FACILITY NAME or DBA-Doing Business As) 3 f? X67 9 BUSINESS SITE ADDRE 103 104 T , II.TANK DESCRIPTION y TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 _/ ❑I.A STAND-ALONE TANK T1411G 0�� `C7 •© ❑Z.ONE TN A COMPARTMENTED UMT. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 CNUMBER OF COMPARTMEINTS 'TIT UNIT 432 O M.TANK USE AND CONTENTS' TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ I b.MARINA FUELING ❑ I c.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)j ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN - C1 99.OTHER(Specify): 439. CONTENTS PETROLEUM: 0 la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ 1 b.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 TYPE OF TANK ❑ L SINGLE WALL TR 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT -STEEL 3.FIBERGLASS El6.INFERNAL BLADDER 444 7.STEEL+INTERNAL LINING El 95.UNKNOWN ❑ 99.OTHER (specify): 444a SECONDARY CONTAINMENT ❑ I.STEEL M 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a 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 I 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)j 458 PRIMARY CONTAINMENT ❑ 1.STEEL in 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4641 ❑ 90.NONE ❑ 95.UNKNOWN E] 99 OTHER(Specify): 464c PIPINGrrURBINE CONTAINMENT SUMP TYPE IV 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI:VENT,VAPOR RECOVERY(VR)AND RISER/FILLINP -PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.FRIGID ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC IM 90.NONE ❑ 99.OTHER(Specify) 464f 464fl VR PRIMARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 4646 464 1 VR SECONDARY CONTAINMENT ❑ L STEEL } 4.FIBERGLASS ❑ 10.RIGID PLASTIC - 90.NONE ❑ 99.OTHER(Specify) 464h VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE a64 464h! RISER PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464j 464.1 RISER SECONDARY CONTAINMENT E 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464kl FILL COMPONENTS INSTALLED ® L SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER`CONTAINMENT."C) CONSTRUCTION TYPE ® I.SINGLE WAI.I. ❑2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL ' 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENF E 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 fi'nk;;accurate, and in full lom Bance with legal requirements. APPLICANTSIGNATURc / (() DATE oG` 420. APPLICANT NAME(print) 421• APPLICM-1�f d7' UPCF UST-B-1/2R .A,.(17&07)