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UNIFIED PROGRAM CONSOLIDATED FORM PO �� UNDERGROUND STORAGE TANK E: OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per U t ? `- 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 IX low 430 ❑ 1.NEW PERMIT R�3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION )i✓ ti \ ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL �i3nkny�W DATE UST PERMANENTLY CLOSED: 430. DATE EXISTING UST DISCOVERED: 30b INFORMATION FACILITY ID#(Agency Use Only) L FACILITY 1 BUSINESS N Same as FACILITY NAME or DBA-Doing Business As) 3 B%SS i RESS 103 CITY I 104 U.TANK DESCRIPTIO TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 3 3 z.c 5 1.A STAND-ALONE TANK u 2.ONE IN A COMPARTMENTED UNM. DATE T SY TEM INSTALLED 435 TANK C eyPAC IN GALLONS Complete one a for each corn rtment in the unit 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 vI III.TANK USE AND CONTENTS TANK USE ❑ le MOTOR VEHICLE FUELING ❑ 1 b.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE J4,4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL(HSC§25281.5(c)l ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN El 99.OTHER(Specify): 439. CONTENTS PETROLEUM: ❑ 1a 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 i : 440a NON-PETROLEUM:R-7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUMS 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL DOUBLE WALL ❑ 95.UNKNOWN PRIMARY CONTAINMENT I.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 443 tj 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444& SECONDARY CONTAINMENT 1.STEEL 113.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 �] 90.NONE ❑ 95.UNKNOWN ❑99.OTHER S 445a OVERFILL PREVENTION �'`� AUDIBLE 8c VISUAL ALARMS ❑ 2.BALL FLOAT 1:1 3.FILL TUBE SHUT-OFF VALVE 452 LJ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PSECONDIRYCONTAINmENT STRUCTION ❑1.SINGLE-WALLED 2.DOUBLE-WALLED ❑99.07VER PE 460 ❑ 1.PRESSURE GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR§2636(.)(3)1 458 ONTAINMENT 4&J.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a Y CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464c BINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALLNONE gb4d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION ARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99OTHER(Specify) 464e NDARY CONTAINMENT 1.STEEL FIBERGLASS 464e1 ❑ 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464f VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 4648 VR SECONDARY CONTAINMENT LJ 1.STEEL U 4.FI1JERGLASS10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4a64h VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL 464h1 RISER PRIMARY CONTAINMENT ❑ 90.NONE 464i_ ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464j RISER SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC [1505.NONE ❑ 99.OTHER(Specify) 464k FILL COMPONENTS INSTALLED 46ak1 ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR CONTAINMENT SUMP 451a< VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ L STEEL El 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 449. 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,accurate, and' ull compliance with legal requirements. APP ICLN�1 DATE /) azo. APP C 471./ APP I ANT ( 472. UPCF UST-B-1/2 Rev.(12/2007)