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• UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one Form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,la,111,IV,and IX below) 430 .9,1.NEW PERMIT Lj3.RENEWAL PERMIT [15.CHANGE OF INFORMATION [16.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 43oa DATE EXISTING ST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agencv Use Only) 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 if I 7�e s/- Ld �� ,Jf� �P.�t S'F�I✓ c BUSINESS SITF ADDRESS 103 e�• CITY / Ov t/ ��• �Z Z 104 II.TANK DESCRIPTION TANK ID#_39000 231 3 Z _ 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS ?o�,✓,� 434 F12.ONE IN STAND-ALONE COMPARTMENTED UNIT. Complete one page for each com amnmt in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN N GALLONS 436 NUMBER OF COMPARTMENT THE UNIT 437 / O/✓ II .TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC 325281.5(c)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION_GAs �� [I8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:t.USED OIL C] 10.ETHANOL 1 I.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT " STEEL C] 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING-_ C3 95.UNKNOWN C199.OTHER (Specify): 444a SECONDARY CONTAINMENT C1 1.STEEL 3.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 ALL P 3.FILL TUBE SHUT-OFF VALVE 452. 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVER REVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑I.SINGLE-WALLED .DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR 32636(a)(3)) 458 PRIMARY CONTAINMENT ❑ I.STEEL jjrj.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ I.STEEL .FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ I.SINGLE WALL MZ2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEELFIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 46417 VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4646 464 I VR SECONDARY CONTAINMENT ❑ I.STEEL ga4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL DOUBLE WALL ❑ 90.NONE 464i. RISER PRIMARY CONTAINMENT j5jor4.STEEL ❑ 4.FIBERGLASS El 10.RIGID PLASTIC El 90.NONE ❑ 99.OTHER(Specify) 4641 464 I RISER SECONDARY CONTAINMENT �2fI.STEEL ❑ 4.FIBERGLASS C1 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED SPILL BUCKET gffl.STRIKER PLATE/BOTTOM PROTECTOR X4.CONTAINMENT SUMP 451 a-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) it, 469b-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT CP,6.ISOLATION 448. 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 in fun compliance with lezal requirements. APPLICANT SIGNATURE �� ,. DATE 470. -3 - / 7- 471, / 7-- APPLICANT NAME(print) T /�� y 471. APPLICANT TITLE A�G AA) r. G C/ UPCF UST-B-1/2 Rev.(12/2007)