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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND OPERATING PERMIT APPLICATION- E TANK T TYPE OF ACTION (Check one item ovly. Foran UST ANI{INFORMATION(Ove form pa UST) ❑ 1.NE W PERMIT 6.TEMPORARY UST CLOSURE 0 3 Z Pemlanevt closuRENEWAL PERMIT reor remgval,complete ovly this section and Sections I,I7,[[i,IV,vvd IX below) 43013 . ❑ 5.CHANGE OF INFORMATION DATE UST PERMANENTLY CLOSED: UST PERMANENT CLOSU ONSITE 8.UST REMOVAL DATE EXISTING UST DISCOVERED: 430bFACB.ITV ID$(Agency Use Only) I. FACII,ITY- ORMATION BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) - - I BUSINESS SITE ADDRESS 3 Im CITY Ia TANK m a IL TANK DE RD'1'ION a12 TANK MANUFACTURER 115 TANK CONFIGURATION:THIS TANK IS 114 ❑L A STAND-ALONE TANK ❑2.ONE INA COMPARTMENTED UNIT, DATE UST SYSTEM INSTALLED a1s TANK CAPACITY IN GALLON 116 dc. f e'B' °1b41me NUMBER OF COMPARTMENTS IN THE UNIT 457 TANK USE ❑ la MOTOR M.TANK USE CONTENTS VEHICLE FUELING 11 Ib.MARINA FUELING ❑ 3.CHEMICAL PRODUCT STORAGE [1 4.HAZARDOUS WASTE(WI usei O10 ❑ IC.A 7ON F GENERATOR FUEL 459 ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN [HSC§25281.5(c)] CONTENTS PETROLEUM; I] la.REGULAR UNLEADED ❑ 99.OTHER(S ft 419a 135.DIESEL ❑ Ic.MIDGRADE UNLEADED ❑ l b.PREMIUM UNLEADED 8. ❑ 5.JET FUEL ❑ 6.AVIATION GAS mu NON-PETROLEUM;Q T.USED O PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S i 44(6 ❑ I L OTHER NON-PETROLEUM S ecffI 10.ETHANOL IV. TAMC CONSTRUCTION 4406 PRIMAR TANK ❑ L SINGLE WALL ❑ 2.DOUBLE WALL PRIMARY COMAI4MEM ❑ 1,STEEL ❑ 95.TJNKNOWN ❑ 3.FBERGLASS ❑ 6.INTERNAG HEADIER 441 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER S SECONDARY CONTAINMENT ❑ L STEEL ❑J.P WERGLASS ❑ 6.EXTERIOR MEMBRANE LI4ER ' ❑ 90.NONE ❑ 95.UNKNOWN 1199,OTHER S ❑ 7.JACKETED 445 OVERFI.L PREVENTION 1.AUD®LE d VISUAL ALARMS 2.BALL FLOAT ) 3.FILL TU13E ^154 [34.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL pitEVEMION EQUIPMENT�� 452 V: PRODUCT`!WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED 012.DOUBLE-WALLED SYSTEM TYPE ❑ 1.PRESSURE ❑99.OTHER PRIMA440 RY CONTAINMENT L STEEL, ❑ 4. ERGLASS 5.CONVENTIONAL SUCTTON ❑ q,SAFE SUCTION 21 CCR§265 eN5) ass ❑ 90.NONE ❑ 95.UNKNOWN ❑S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 SECONDARY CONTAINMENT (] 1.STEEL 99.OTHER($Pecify): ❑ 4.FIBERGLASS ❑g.FLEXIBLE ' ❑90.NONE ❑ 95.UNKNOWN I]99.OTHER ❑ 10.RIGID PLASTIC 4646 PIPINC?URB(NE CONTAINMENT SUMP TYPE (Specify): 464c ❑ L SINGLE WALL 2.DOUBLE WALL 90.NONE VI VENT,VAPOR RECOVERY I YAP AND RISERS FILL PIPE PIPING CONSTRUCTION � VENT PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS10.RIGID PLASTIC 90.NUNE 99.OTHER(SPecify) 464 VENT SECONDARY CONTAINMENT ❑ L STEELU 4.rmbKULASS L1 10.RIGID PLASTIC ❑ 90.NONE 99.O7HER(Specify) a64f VR PRIMARY CONTAINMENT I.STEEL I.F®ERGLASS Lj 10.RIGID PLASTIC mfl VR SECONDARY CONTAINMENT ❑ 90.NONE 99.OTHER(Specify) ter ❑ I.STEEL 4.FIBERGLASS !0.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 44616 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WgLL RISER PRIMARY CONI2.DOUBLE WALL 90.NONEi1 1.STEEL 4,FBSERG[.ASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464 RISER SECONDARY CONTAINMENT I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) abet 4M'I FILL COMPONENTS INSTALLED C .SPILL 1 :1 IITSTIIII R I I III lB07TOM PROTECTOR 4.CONTAINMENT•SUMP 45j `I VII.UNDER DISPENSER CONTAINMENT lU CONSTRUCTION TYPE ❑ LSINGLE WALL CONSTRUCTION MATERWI. J STEEL O 2.DOUBLE WALL ❑J.NO DISPENSERS ❑ 90.NONE 469a ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(S VDI. CORROSION PROTECTION ) 469bc STEELCOMPONENTPROTECTION ❑ 2.SACR@TCNLANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 44R AN JI RE CERTIFICATION: I certlfy that this UST system Is compatlb w�thL hCaza Ssubatavicestored end that the Information provided herein b true,accurate, and b fuB com Bance with of uiroments. APPLICANT SIGNATURE DATE am. APPLICANT NAME(print) 421, APPLICANT T1TLE 4]+ UPCF UST-B-112 Rev.(1212007)