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BFGE1A1[-= . W 0"M UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK 0 C r ,7 OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per`'U� TYPE OF ACTION (Check one item only_ For apA19T permanent closure or removal,complete only this section and Sections 1,IL III,IV,and IX below) 430 1 NEW PERMIT 3.RENEWAL PERMIT ❑ 5.Ct1A� AL HEALTH 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMO DATE UST PERMANENTLY CLOSED: 431a DATE EXISTING UST DISCOVERED: ULHARTMENT 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ 1 BUSINESS NAME(Same as FACILITY NAMT,or DBA-Doing Business As) 3 AA BUSINESST DRE '9;-, 103 CITY 104 _ T II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 f A STAND-ALONE TANK T2.ONE IN A COMPARTMENTED UNIT. Com lett one pga for each com 1 in the unit DATE UST SOTEM INSTALLED 435 TAVR CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 !� C20 0 0 M.TANK USE AND CONTENTS TANK USE [j-,Ia.MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ lc.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑4.HAZARDOUS WASTE(I.cl.dcz Uccd Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§252815(c)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: -REGULAR UNLEADED ❑ I..MIDGRADE UNLEADED El Ib.PREMIUM UNLEADED 440 RLJ 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.OTHERNON-PETROLEUM S ec 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL .DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ L STEEL PL3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL QV.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 415 ❑ 90.NONE C1 95.UNKNOWN ❑99.OTHER(Specify): 445. OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑2.BALL FLOAT X3.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 [r.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(.)(3)] 458 PRIMARY CONTAINMENT ❑ l_STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE 95_UNKNOWN ❑ 99.OTHER(Specify): 464. SECONDARY CONTAINMENT ❑ 1.STEEL 5JC4_FIBERGLASS ❑ 8_FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95_UNKNOWN ❑ 99.OTHER(Specify): 464. PIPINGITURBINTE 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 ❑ L STEEL �4.FIBERGLASS Ll10.RIGIDPLASTIC El 90.NONE [199.OTHER(Specify) 464c 464.1 VENT SECONDARY CONTAINMENT ❑ L STEEL to:4.FIBERGLASS ❑ I0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT ❑ I.STEEL19 4.FIBERGLASS ❑ to.RIGID PLASTIC ❑ 90.NONE [199.OTHER(Specify) 4649 464=1 VR SECONDARY CONTAINMENT ❑ I.STEEL Qg 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 4601 VENTPIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL .DOUBLE WALL ❑ 90.NONE 4641 RISER PRIMARY CONTAINMENT ].STEEL ❑ 4.FIBERGLASS ❑ l0.RIGIDPLASTIC ❑ 90.NONE [199.OTHER(Specify) 464) 464j I RISER SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 10_RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FELL COMPONENTS INSTALLED 1.SPILL BUCKET .STRIKER PLATEBOTTOM PROTECTOR 5L4.CONTAINMENT SUMP 451x, VII.UNDER ISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL E%0.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL EK4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 409 VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑4.IMPRESSED CURRENT ❑ 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, ang in full compliance with legal requirements. APPLICANT SIGNATAkj DATE 4�0. APPLICANT NAME(print) /� 471 APPLICANT TITL 472' UPCF UST-B-112 Rev.(1212007)