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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 US ermanent closure or removal, complete only this section and Sections 1, 11, 111, IV, and IX below) 431' 1_ NEW PERMITRENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 430'' DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) _ 1 BUSINESS NAME (Same as FACTLIT NAME r DAL�ess As) 3 aAfZ 7-Y q 103 BUSINESS SITE Aj2D SS ` r CITY 104 (( nJ d - II. TANK DESCRIPTION TANK ID # 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 ❑ 1. A STAND-ALONE TANK [WONE IN A COMPARTMENTED UNIT. Complete one page for mch com t in the unit. DATE UST SYSTEM INSTALLED 435 Tt&K CAPAVtY IN GALLONS 436 NUMBER OF C PARTMENTS IN THE UNIT 437 Uxn'� III. tANK USE AND CONTENTS TANK USE la. MOTOR VEHICLE FUELING ❑ lb. MARINA FUELING ❑ Ic. AVIATION FUELING 439 R 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Includes Uaed Oil) ❑ 5. EMERGENCY GENERATOR FUEL [HSC W281.5(c)] ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la. REGULAR UNLEADED ❑ Ic. MIDGRADE UNLEADED ❑ ]b. PREMIUM UNLEADED 440 W3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (Specify): 440. NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ❑ 11. OTHER NON -PETROLEUMS 440h IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL 4 2. DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1. STEEL Ejr3. FIBERGLASS [16. INTERNAL BLADDER 444 ❑ 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 444a FERGLASS ❑ 6. EXTERIOR MEMBRANE LINER [17. JACKETED 445 SECONDARY CONTAINMENT ❑ L STEELB ❑ 90. NONE [95. UNKNOWN ❑ 99.OTHER S c' 445a OVERFILL PREVENTION ❑ 1. AUDIBLE & VISUAL ALARMS ❑ 2. BALL FLOAT I E 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 DOUBLE -WALLED [199. OTHER 460 SYSTEM TYPEPRESSURE [12. GRAVITY ❑ 3. CONVENTIONAL SUCTION [14. SAFE SUCTION [23 CCR §2636(1x3)) 458 PRIMARY CONTAINMENT 1Pj . STEEL 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE 95. UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1. STEEL FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 4646 �4. ❑ 90. NONE 95. UNKNOWN ❑ 99. OTHER (Specify): 464c PfPINGNURBINE CONTAINMENT SUMP TYPE ❑ I. SINGLE WALL . DOUBLE WALL ❑ 90. NONE 4644 VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ L STEEL4. FIBERGLASS ❑ I0. R[GfD PLASTiC El90. NONE ❑ 99. OTHER (Specify) 464c 464c l VENT SECONDARY CONTAINMENT ❑ L STEEL4. FIBERGLASS ❑ 10. RIGID PLASTIC 90. NONE [199. OTHER (Specify) 464r 464fl VR PRIMARY CONTAINMENT ❑ 1. STEEL X4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 4648 461 1 VR SECONDARY CONTAINMENT ❑ L STEEL WA. FIBERGLASS ❑ 10. RIGID PLASTIC [1 90. NONE ❑ 99. OTHER (Specify) 464h 4601 VENT PIPING TRANSITION SUMP TYPE I. SINGLE WALL LW. DOUBLE WALL Q 90. NONE 4641. RISER PRIMARY CONTAINMENTI. STEEL El 4. FIBERGLASS E]10_ RIGID PLASTIC [190. NONE ❑ 99. OTHER (Specify) 464i 464' l RISER SECONDARY CONTAINMENT ❑ 1. STEEL Pt 4. FIBERGLASS 10. RIGID PLASTIC 90. NONE ❑ 99. OTHER (Specify) 464k 464k1 FILL COMPONENTS INSTALLED NEI. SPILL BUCKET NJ 3. STRIKER PLATEBOTTOM PROTECTOR 4. CONTAINMENT' SUMP 45la-c VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ❑ 1. SINGLE WALL DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 469a CONSTRUCTION MATERIAL ❑ I. STEEL 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 469b -c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION 448. W. 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 com I Pnce with legal requirements. APPLICANT SIGNATURE _ aio. DATE 4O _ APPLICANT NAMEjnn ��! 471.APPLICANT ///�yf/Irl --or - TITLE 472' UPCF UST -B -1/2 Rev. (12/2007)