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P1=r.1=1x1C:r-) UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANKn QwkM 17 OPERATING PERMIT APPLICATION - TANK INFORMATION (one f T TYPE OF ACTION (Check one item only. For T permanent closure or removal, complete only this section and Sections I, IL III, IV, andIX below) A30 L NEW PERMIT 3. RENEWAL PERMIT [15. CRA Q1 P�l AL V 1 HEALTH6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REM DATE UST PERMANENTLY CLOSED: 43°8 DATE EXISTING USTDISCOVERED: ULHARTMENT 430b I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) BUSINESS NAME (Same as FACILITY NAW or DBA -Doing Business As) 3 BUSINESINrDRE, CITY M 104 j/' II. TANK DESCRIPTION TANK ID # 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 STAND-ALONE TANK 'A Z. ONE IN A COMPARTMENTED UNIT. Complete one page for e h corn t in the unit DATE UST SYSTEM INSTALLED 435 TAYK CAPACITYIN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNDP 437 070 00 1 M. TANK USE AND CONTENTS TANK USE MOTOR VEHICLE FUELING ❑ 1 b. MARINA FUELING Ellc_ AVIATION FUELING 439 �la. 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Indad. U -d Oil) ❑ 5. EMERGENCY GENERATOR FUEL [HSC §25281.5(e)] ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439a CONTENTS PETROLEUM: g0a. REGULAR UNLEADED ❑ lc. MIDGRADE UNLEADED ❑ 1b. PREMIUM UNLEADED 440 [l 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9- OTHER PETROLEUM (Specify); 440a NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ❑ 11. OTHER. NON -PETROLEUM (Specify): 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL . DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1. STEEL . FIBERGLASS ❑ 6.1NTERNALBLADDER 444 ❑ 7. STEEL +]NTERNAL LINING [195. UNKNOWN ❑ 99. OTHER Specify): 444a SECONDARY CONTAINMENT ❑ 1. STEEL W. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445 ❑ 90. NONE [195. UNKNOWN ❑ 99. OTHER (S 445a OVERFILL PREVENTION ❑ 1. AUDIBLE & VISUAL ALARMS ❑ 2. BALL FLOAT 5D. FILL TUBE SHUT-OFF VALVE 452 ❑ 4. TANK MEETS REQUMEMENTS FOR EXEMPTION FROM O L PREVENTION EQUIPMENT V. PRODUCT / WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1. SINGLE -WALLED IV. DOUBLE -WALLED ❑ 99. OTHER 460 SYSTEM TYPE 1. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR §2636(a)(3)] 458 PRIMARY CONTA T4.M N'T ❑ 1- STEEL 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE 95. UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1. STEEL W4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 4646 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 46ac PIPINGITURBINE CONTAINMENT SUMP TYPE ❑ 1. SINGLE WALL W. DOUBLE WALL ❑ 90. NONE 464d VL VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1. STEEL�4. FIBERGLASS L]10. RIGIDPLASTIC 1:190. NONE El99.OTHER (Specify) 464c 464el VENT SECONDARY CONTAINMENT ❑ 1. STEEL [* 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90_ NONE ❑ 99. OTHER (Specify) 464f 46441 VR PRIMARY CONTAINMENT ❑ 1. STEEL19 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE El99.OTHER (Specify) 4649 464 I VR SECONDARY CONTAINMENT ❑ 1. STEEL 4. FIBERGLASS ❑ 10. RIGIDPLASTIC ❑ 90. NONE [199. OTHER (Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ 1. SINGLE WALL . DOUBLE WALL ❑ 90. NONE 4641. RISER PRIMARY CONTAINMENT1. STEEL [34. FIBERGLASS ❑ I0. RIGIDPLASTIC ❑ 90. NONE [199.OTHER (Specify) 464] 464' 1 RISER SECONDARY CONTAINMENT ❑ 1. STEEL FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE [199. OTHER (Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1. SPILL BUCKET PL,3.STRUURPLATEn3OTrOMPROIECrOR 4. CONTAINMENT SUMP 451x, VII. UNDER bISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ❑ 1. SINGLE WALL qQ. DOUBLE WALL [13. NO DISPENSERS ❑ 90. NONE 469a CONSTRUCTION MATERIAL ❑ 1. STEEL ErA. FIBERGLASS ❑ l0. RIGID PLASTIC ❑ 99. OTHER (Specify) 469b -c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) [14. IMPRESSED CURRENT ❑ 6. ISOLATION 4a8. 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, ang in full compliance with legal requirements. APPLICANT SIGNA DATE"' APPLI,CANT NAME (print) t /� 471' ovz) APPLICANT TITL 4n' UPCF UST -B -112 Rev. (12/2007)