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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 I, Il, 111, IV, and IX below) 430 1. NEW PERMIT "'� . RENEWAL PERMIT [-]5. CIIANGE OF INFORMATION 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 43oa DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY fD # (Agency Use Only) _ I BUSINESS NAME (Same as FACILITY NAME or A-Doing Business As) 3 BUSINESS SITE ADDRESS( 103 CITY 104 H. TANK DESCRIPTION TANK ID # 432 oil TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 ❑ LA STAND-ALONF. TANK ONE IN A COMPARTMENTED UNIT . om ete nne e for each com tncnt in the unit DATE UST SYSTEM INSTALLED 435 au ie TAN CAPACITY IN GALLONS 436 (7, o ID CD NUMBER OF COMPARTMENTS IN THE UNIT 437 III. TANK USE AND CONTENTS TANK USE Qin a. MOTOR VEHICLE FUELING ❑ Ib. MARINA FUELING ❑ la AVIATION FUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Ina.&e Us.xl Oil ❑ 5. EMERGENCY GENERATOR FUEL tliSC §25281.5(y] ❑ 6. OT HER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la REGULAR UNLEADED ❑ Ic. MIDGRADE UNLEADED X11b. PREMIUM UNLEADED 440 ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ R. 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 WALL2. DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1. STEEL 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 ❑ 7. STEEL A. INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1. STEEL E%V. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE. LINER ❑ 7. JACKETED 445 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 445. OVERFILL PREVENTION ❑ 1. AUDIBLE & VISUAL ALARMS ❑ 2. BALL FLOAT rg::3. 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 W. DOUBLE-WALLED ❑ 99. OTHER 460 SYSTEM TYPE jW 1. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION (23 CX:R §2636(a)i3)] 458 PRIMARY CONTAINMENT ❑ 1. STEEL W4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE. ❑ 95. UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1. STEEL �4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464b ❑ 90. NONE 95. UNKNOWN ❑ 99 OTHER (Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ I. SINGLE WALL IR 2. DOUBLE. WALL ❑ 90. NONE 461d VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1. STEEL IR 4. FIBERGLASS ❑ I0. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464c 464,1 VENT SECONDARY CONTAINMENT ❑ 1. STEEL�j 4. FIBERGLASS ❑ 10_ RIGID PLASTIC ❑ 90. NONE [199. OTHER (Specify) 464f 11__ 464f1 VR PRIMARY CONTAINMENT ❑ 1. STEEL (L,t. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 4648 464gl VR SECONDARY CONTAINMENT ❑ I. STEEL 4. FIBERGLASS ❑ 10. RIGIDPLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464h 4601 VENT PIPING TRANSITION SUMP TYPE 1. SINGLE WALL Mt. DOUBLE WALL 90. NONE 464i. RISER PRIMARY CONTAINMENT X.STEEL ❑ 4. FIBERGLASS ❑ 10. RIGIDPLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464] 46f1 RISER SECONDARY CONTAINMENT ❑ I. STEEL F,4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE 99. OTHER (Specify) 464k 464k FILL COMPONENTS INSTALLED KLI.SPILLBUCKET A 3. STRIKER PLATEIBOTTOM PROTECTOR Cr4. CONTAINMENT SUMP 451a-c VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ❑ 1. SINGLE WALL X2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 469a CONSTRUCTION MATERIAL ❑ 1. STEEL a 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99.OTHER (Specify) 469b- 11I. 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 DATE470. APPLICANT NAM rin �V 471 _ ' APPLICANT TITLE 477 UPCF UST -B -1/2 Rev. (12/2007)