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is 41 o T erll?I UNIFIED PROGRAM CONSOLIDATED FORM 0-1119UNDERGROUND STORAGE TANK U OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. For ap UST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX 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: 4304 DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ _ C. 1 BLJSWESS N (Same as FACILITY NAME or DBA-Doing Business As) 3 S7_0SITE ADDRES 103 CITY d 1 104 B Alft_z Le II.TANK DESCRIPTIO 6 TANK ID# /1 37) ;, 432 TANK MANUFACTURER 433 rTr�AA(^^N��K CONFIGURATION: THIS TANK IS 434 3R o 00 2 313 320(33 2 04 lAA STAND-ALONE TANK �a 2 ONE IN A COMPARTMENTED UNIT. Conaplete one a for each compartment in the unit. DATE UST SYSTELIINSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 l7 -o ONE- III. EIII.TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: [,la REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT I.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S ): 444a SECONDARY CONTAINMENT 1.STEEL ❑3.FIBERGLASS [16.EXTERIOR MEMBRANE LINER El7.JACKETED 445 90.NONE ❑ 95.UNKNOWN [199.OTHER(S ify): 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/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED 2.DOUBLE-WALLED ❑99 OTHER 460 SYSTEM TYPE N 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(a)(3)) 458 PRIMARY CONTAINMENT VLLSTEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT QLLSTEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 4646 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464c 'P[P1NGlfURB)NE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.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 1-199.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464f 4641`1 VR PRIMARY CONTAINMENT ❑ 1.STEEL XL4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464RI VR SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE Lj 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC Ij 90.NONE ❑ 99.OTHER(Specify) 4641 464'1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99 OTHER(Specify) 464k 464k FILL COMPONENTS INSTALLED 1.SPILL BUCKET X 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL 1.STEEL M4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION Of%2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 4.' IX. APPLICANT SIGNATURE ' CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,Atggr04 and in full compliance with legal requirements. a A031CANT SIGNA�j' DATE 4V AP C� C AT(print) 471 A IC TI E / e� z. J� /`e N� UPCF UST-B-112 Rev.(121200'