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RPC.pw 'n . . Z ._, UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK2,nQ for ®perST)1 OPERATING PERMIT APPLICATION - TANK INFORMATION (on TYPE OF ACTION (Check one item only- For ap,411ST permanent closure or removal, complete only this section and Sections 1, 11, 111, IV, and IX below) 430 1. NEW PERMIT 3. RENEWAL PERMIT ❑ 5. CH^�r�-AL 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ & UST REM A HEALTH DATE UST PERMANENTLY CLOSED. 4301 DATE EXISTING UST DISCOVERED: ULFARTMENT 430b I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) _ I BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) 3 AA Al BUSINES T DD r C 103 = T CITI°} Y II. TANK DESCRIPTION TANK ID # 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 A STAND-ALONE TANK 1 2.ONE TNA COMPARTMENTED UNIT. Com ee one a for each com tin the unit DATE UST S3TEM INSTALLED 435 TAVk CAPACITYIN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 D M. TANK USE AND CONTENTS TANK USE MOTOR VEHICLE FUELING ❑ Ib. MARINA FUELING ❑ lc. AVIATION FUELING 439 Pr,la 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Ind d. Used Oil) ❑ 5. EMERGENCY GENERATOR FUEL [HSC ¢25281 S(e)I ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 4394 CONTENTS PETROLEUM:[�(ja REGULAR UNLEADED ❑ Ic. MIDGRADE UNLEADED ❑ Ib. PREMIUM UNLEADED 440 d 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (Specify): 4402 NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ❑ 11. OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL NFO. DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1. STEEL M.3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 ❑ 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 441a SECONDARY CONTAINMENT ❑ L STEEL FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445 ❑ 90. NONE 95. UNKNOWN ❑ 99.OT14ER(Specify): 44U OVERFILL PREVENTION ❑ 1. AUDIBLE & VISUAL ALARMS ❑ 2. BALL FLOAT X3. FILL TUBE SHUT-OFF VALVE 452. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVER FILL PREVENTION EQUIPMENT V. PRODUCT / WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1. SINGLE -WALLED W. DOUBLE -WALLED ❑ 99. OTHER 460 SYSTEM TYPE1. PRESSURE ❑ 2. GRAVITY [33. CONVENTIONAL SUCTION [14. SAFE SUCTION [23 CCR §2636(a)(3)] 458 PRIMARY CONTAINMENT 1. STEEL 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ I0. RIGID PLASTIC 464 ❑ 90. NONE 95. UNKNOWN ❑ 99. OTHER(Specil'y): 4642 SECONDARY CONTAINMENT ❑ 1. STEEL (SC4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464h ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464c PIPINGrnjRBINE CONTAINMENT SUMP TYPE ❑ 1. SINGLE WALL . DOUBLE WALL ❑ 90. NONE 464d VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT El 1. STEEL�4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE [199.OTHER (Specify) 464c JM4 l VENT SECONDARY CONTAINMENT 1. STEEL Eg 4. FIBERGLASS 0 10. RIGID PLASTIC ❑ 90. NONE 0 99. OTHER (Specify) 464( 464n VR PRIMARY CONTAINMENT ❑ 1. STEEL 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 4648 464 I VR SECONDARY CONTAINMENT ❑ 1. STEEL Qj 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 1. SINGLE WALL CFA. DOUBLE WALL ❑ 90. NONE 4641. RISER PRIMARY CONTAINMENT1. STEEL ❑ 4. FIBERGLASS [I10. RIGID PLASTIC Ll 90. NONE ❑ 99. OTHER (Specify) 4641 464' I RISER SECONDARY CONTAINMENT ❑ 1. STEEL . FIBERGLASS ❑ 10. RIGIDPLASTIC ❑ 90. NONE 99. OTHER (Specify) 464k 464k1 FILL COMPONENTS INSTALLED SLLSPILLBUCKET . STRIKER PLATEBOTTOM PROTECTOR ISL4. CONTAINMENT SUMP 4512-c VII. UNDER bISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ❑ L SINGLE WALL qq. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 46% CONSTRUCTION MATERIAL ❑ 1. STEEL . FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 469Mc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION 448. IX. APPLICANT SIGNATURE CF,RTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate, an in full compliance with legal requirements. APPLICANT SIGNA DATE 91U APPLICANT NAME 471 APPLICANT 11TL 477 UPCF UST -B-1/2 Rev. (12/2007)