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-6 - 2 r -) -7/, /7 1v UNIFIED PROGRAM CONSOLIDATED FORM )/(] /y I .� UNDERGROUND STORAGE TANK I�-�C _I 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,Il,Ill,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 ❑ &UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a FDATE EXISTING UST DISCOVERED: 4306 FACII,ITY ID#(Agency Use Only) L FACILITY INFORMATION BPS (Same as FACILITY NAME or DBA-Doing Business As)dltlBTE ADDRES 103 CITY A 104 �� H.TANK DESCRIPTIO TANK TANK ID# �32 MANUFACTURER 433 C) 1.A STAND-ALONE TANKS TANK IS 43a �j 0 DO 2-3 3 Z O t ZO-7 ❑2.ONE IN A COMPARTMENTED UNIT, DATE UST SYSTEM INSTALLED 435 TANK C ACII Y RV GALLONS 436 NUMBER OF COMPAORUComplete one me for each mTM�NTS IN THE UNIT 437 ent in the unit. Q � III.TANK USE AND CONTENTS TANK USE in.MOTOR VEHICLE FUELING ❑ ib.MARINA FUELING ❑ lc.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(includes Used Oil) [1 5.EMERGENCY GENERATOR FUEL(HSC§25291.5(e)] El6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: la REGULAR UNLEADED ❑ Ic.MDGRADE UNLEADED El lb.PREMIUM UNLEADED 440 3.DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUMS 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL tj 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT 1.STEEL [13.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 Lj 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION $IPING CONSTRUCTION ❑1.SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OT}]Eg 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR 12636(a)(3) ass PRIMARY CONTAINMENT 1.STEEL Ll 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a s ECONDARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ B.FLEXIBLE ❑ M RIGID PLASTIC 4646 ❑ 90.NONE Q 95.UNKNOWN ❑ 99.OTHER(Specify): 464c IPING/TURBINE CONTAINMENT SUMP TYPE JR L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS El 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 464e VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS4 ❑ 10.RIGID PLASTIC ❑ 90.NONE LJ 99.OTHER(Specify) 464£ VR PRIMARY CONTAINMENT a64ri ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ ]0.RIGID PLASTIC K 90.NONE ❑ 99.OTHER(Specify) 4648 VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC X�90.NONE 0 99.OTHER(Specify) 464h VENT PIPING TRANSITION SUMP TYPE iL 1.SINGLE WALL464hl RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS El NONE 464i. ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464j RISER SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 91-N.NONE ❑ 99.OTHER(Specify) 464k FILL COMPONENTS INSTALLED I.SPILL BUCKET 3.STRIKER FLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 4511 VII-UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(S `4696 c VIII- CORROSION PROTECTION STEEL COMPONENT PROTECTION 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 44e. 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,accttrate, and in full com liance with I al reuirements. ICANT SIGNA DATE 470. AP C j1 N (print) a71. ICA IT E an. UPCF UST-B-IR Rev.(12/2007)