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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND OPERATING PERMIT APPLICATION-TAN NFORMATION(One co m UST) GE TANK TYPE OF ACTION (Cheri one item only. For an UST prnnBnam closwe or rerroval,compluye only Wia section and Sectiore I,II,III,ry aad IX ST) ) ❑ I.NEW PERMIT ❑ 3.RENEWAL PERMIT ti.l'EMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 0 5.CHANGE OF INFORMATION 4501 UA I'E I;ST PERMANENTLY CLOSED: 4Jae S.UST REMOVAL DATE EXISTING UST DISCOVERED: Gat I FACILITY ID x(Agency Use Only) 1. FACILITY INFORMATION - I BUSINESS NAME(Same ns FACILITY NAME qr DdA-Duine Business As) S1123 dUSiNI-SN SITE ADDRESS 16888 McKim ey 0J CITY IN r Nk 1D 1, iI.TANK DESCRIPTION j FANK MANUFACTURER qJ TANK CONFIGURATION: THIS TANK IS ✓ N� I [$I.A STAND-ALONE'rANK +N S ❑2.ONE IN A COMPARTMENTED UNIT. D,TL UST SYSTE )]JSTALLED +55 TgNK CAPACITY M GALLONS +J6 f '.a L r'( NUMBER OF COMPARTMENTS IN THE UNIT ut TANK USE }E] la.MOTOR VEHICLE FUELING III'TANK USE AND CONTENTS b. ] 3.CHEMICAL PRODUCT STORAGE IMARINA FUELING ❑ IC.AVIATIONFUELING ❑ 4.HAZARDOUS WASTE(Mr uW oil) 439 ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 5.EMERGENCY GENERATOR FUEL IHSC 6LR01.Xc11 CONTENTS PETROLEUM: ❑ N.REGULAR UNLEADED ❑ 99 OTHER (S ); 4194 10 J.DIESEL ❑ la MIDGRADE UNLEADED U Ib.PREMIUM UNLEADED 41a Tank #1 ❑ 8.PETROLEUM BLEND FUEL IJ 9.OTHERE ETROLEUM 6.AVIATION GAS - NON-PETROLEUM:[) OTHER 7.U$EO OILNDN-PETROLEUMS ❑ $ I NW 10.ETHANOL II. i y.�. IV. TANK CONSTRUCTION 4«n ! R'PE(:i"fgNK LSINOLEWALL ?.DOUBLEWALL 95.UNKNOWN Ir PRIlIAlt S'CONTAINMENT LSTEEL 1.FIBERGLAS$ 44J I- ❑ 7.STEEL-INTER AL LINING 95.UNKNOWN BIADDER ❑ 95.UNKNOWN 99.OTHER S I 4w SEC'O%UAµy CONTAINMENT ❑ LSTEEL ��]]).FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER 7.JACKETED +I4r ❑ W.NONE 1] 95.UNKNOWN N5 OV 'I,L PREVE ION LAUDIBLE9 VISUAL ALARMS 2.RAI[ETHER IS ); J.FILL TUBE SHUT-OFF VALVE 1154 d L"' ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT +3. V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING('ONSTRUCTIO.4 O 1.SINOLE-WALLED 2.DOUBLE-WALLED 99.OTHER ' SYSTEM 11PE LPRESSURE ❑ ±,GRAVRVU (.CONVENTIONAL SUCTION 4.SAFE SUCTION 23 CCR 365 5) 4460 50 YR&Iak'i CONTAINMENT ❑ 1.STEEL [ 4.FIBERGLASS B.FLEXIBLE ❑ 90.NONE (7 95.UNKNOWN0 10.RIGID PLA$7'IC 'SEEca'a ARY CONTAINMENT ❑ I $TEFL 4. 0 99.OTHER(Spaify): abet . FIBERGLASS B.FLEXIBLE 10.RIGID PLASTIC ❑ 90.NONE 45.UNKNOWN ❑ 99,OTHER(Speeifyl: 464t PIPINGi T'URBIN'E CONTAINMENT SUMP TYPE ❑ I SINGLE WALL ❑ 2.DOUBLE WALL ` VI.VENT,VAPOR RECOVERY 90.NONE 1648 ,r.%7 PRinuftY coNTaINMErvr ��'R)AND RISER/FILL PIPE PIPING CONSTRUCTION I.$TEFL 4.FIBERGLAS$ 10.RICID PLASTIC L'EN'T SE90.NONE 99.OTHER(Specify) 46c I CONDARY CONTAINMENT LSTEEL LFIBERGLASS 10.RIGID PLASTIC 90.NONE VR PRIALIRY CONTAINMENT 99.OTHER(Specify) 461f 1.$TEFL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER($pscify) 4�n \'R SECONDARY CONTAINMENT LSTEEL V.FIBERGLAS$ 10.RIGID PLASTIC +6+ , 90.NONE 99. OTHER(Spmify) 64 1 PENT?IPiN'G TRANSITION SUMP TYPE I.SINGLE WALL ].DOUBLE WALL V64t1 kUSER PRL'.14RY fONTAMMENT LSTEEL +.FIBERGLASS 10.RIGID PLASTIC 90,NONE 4N: 90.NONE 99.OTHER(Specify) 4N ERT :UN'DARS'CONTAINbIENT LSTEEI- 4.FmERGLAS$ 10.RIGID PLASTIC 90.NONE 99,OTHER(Specffy) 41 64 Ft LCUSIPU.NENTS INSTALLED I SPILL BUCKET 3 STRIKER PLATE/BOTTOM PROTECTOR 4 CONTAINMENT SUMP 1641 VH UNDER DISPENSER CONTAINMENT ul4 c I CONSTRC'.-..TYPE LSINGLE WALL lu CONSikCC?ION MATERWL ❑ �.DOUBLE WALL ❑ 3=L,.ATION NO DISPENSERS ❑ 9U.NONE 469r I.$TEFL 4.FIBERGLAIGID PLASTIC 99.OTHER(S i )VIII. CORROTECTIONNENTPROTECTION O 2 SAC'RIEICIALANOI/EfS) PRESSED CURRENT ❑ 6.ISOLATION 4HLX. APPLNATURE CERT IF IC':eTION: I cenlfy that fillUSl' yxlemiscumpuible with Westance stored soft ghat tie InfornutlOn prnVlded'h tela Is true accurate, nd In FuB compBnu ro ith legal requirements'.APPLIC.N'T SIG4m. � 12- - oAPPLICAN FNAME(prit) ANTTITLEKevinSalby _ :' �4T CPCF UST-IJ.I/Z Rev.(12/2007)