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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One formperUST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,1I,III,IV,and IX below) 430 1.NEW PERMIT ®-.RENEWAL PERMIT El5.CHANGE OF INFORMATION TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID# A enc7'Use Only) I 8 BUSINESS NAME(Same as FACILITY NAME orWA-Doing Business As) 3 ✓�C�,J BUSINESS S(ADDRESS � ' � t 1D3 CITY 104 H.TANK DESCRIPTION TANK ID# ^ 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 ❑LA A STAND-ALONE TANK ONE INA COMPARTMENTED UNIT. om tete one pa c for each n= atanrnt in the unit DATE UST SYSTEM INSTALLED 435 TAW CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 tyAt�� 00 eD M.TANK USE AND CONTENTS TANK USE [�na.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ 1 c AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Inclu ky Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL(HSC§25281.5(c)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED 9CIb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS ❑ S.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 W2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ L STEEL &3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444. SECONDARY CONTAINMENT ❑ I_STEEL 59.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95_UNKNOWN [199.OTHER(Specify): 445a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2 BALL FLOAT [9%3.FILL TUBE SHUT-OFF VALVE 452, ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVER UL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED .DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE JW I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR g2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL W.4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Speciry): 464s SECONDARY CONTAINMENT ❑ 1.STEEL �4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b El 90.NONE 95.UNKNOWN ❑99.OTHER(Specify): 464c PIPINGffURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL 2 DOUBLE WALL ❑ 90_NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I.STEEL [W 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464c 464°1 VENT SECONDARY CONTAINMENT ❑ I_STEEL �4.FIBERGLASS ❑ 10_RIGID PLASTIC ❑ 90_NONE [199.OTHER(Specify) 464f 464fl VR PRIMARY CONTAINMENT ❑ 1.STEEL 9JL 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464°1 VR SECONDARY CONTAINMENT ❑ I.STEEL W.FIBERGLASS ❑ 10_RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464h VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL DOUBLE WALL ❑ 90.NONE 464i. RISER PRIMARY CONTAINMENT STEEL ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 464il RISER SECONDARY CONTAINMENT ❑ I_STEEL F„4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90,NOME ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED .SPILL BUCKET a 3.STRIKER PLATE/BOTTOM PROTECTOR Cr4.CONITAINMENTSUmp 451a< VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ I.SINGLE WALL .DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ I O.RIGID PLASTIC ❑ 99.OTHER(Specify)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, and in full compliance with legal requirements. APPLICANT SIG RE DATE ato. 5 APPLICANT NA rint 471 APPLICANT TITLE 472' UPCF UST-B-1/2 Rev.(12/2007)