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dl <br /> UNIFIED PROGRAM CONSOLIDATED FORM Q[ <br /> UNDERGROUND STORAGE TANK l ���D <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) <br /> TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 430 <br /> ❑ 1.NEW PERMIT N 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 43041 DATE EXISTING UST DISCOVERED: 430b <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) _ +� <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 <br /> Safeway Fuel Station 2600-10 <br /> BUSINESS SITE ADDRESS 103 CITY 104 <br /> 1987 West 11th Street Trac <br /> II.TANK DESCRIPTION <br /> TANK ID# 1 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 <br /> Modem Welding ®1.A STAND-ALONE TANK <br /> ❑2.ONE IN A COMPARTMENTED UNIT. <br /> Complete one page for each cwnpamnent in the unit. <br /> DATL UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 <br /> 9/2002 20,000 1 <br /> III.TANK USE AND CONTENTS <br /> TANK USE ® la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Ic.AVIATION FUELING 439 <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used 00) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a <br /> CONTENTS PETROLEUM: N la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUM(Specify): 440b <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL N 2.DOUBLE WALL ❑ 95.UNKNOWN 443 <br /> PRIMARY CONTAINMENT ® I.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a <br /> OVERFILL PREVENTION ® 1.AUDIBLE&VISUAL ALARMS N 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑1.SINGLE-WALLED N 2.DOUBLE-WALLED ❑99.OTHER 460 <br /> SYSTEM TYPE ® L PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(x)(3) 459 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS N 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a <br /> SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ® 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c <br /> PIPTNG=BTNE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d <br /> VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464e <br /> 464e1 <br /> VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE C3 99.OTHER(Specify) 464f <br /> 464n <br /> VR PRIMARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 <br /> 464g I <br /> VR SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify) 464h <br /> 464hl <br /> VENT PIPING TRANSITION SUMP TYPE I.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 4641. <br /> RISER PRIMARY CONTAINMENT N 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464) <br /> 464'1 <br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS El 10.RIGID PLASTIC U 90.NONE 99.OTHER(Specify) 464k <br /> 464k1 <br /> FILL COMPONENTS INSTALLED 1.SPILL BUCKET N 3.STRIKER PLATE(BOTTOM PROTECTOR N 4.CONTAINMENT SUMP 45la-c <br /> VII.UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b-c <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, <br /> and in f 1 compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 9/3/2009 "°' <br /> APPLICANT NAME(print) Butch Hobson 471. APPLICANT TITLE Safety and Environmental Affairs Mgr 477 <br /> UPCF UST-B-112 Rev.(1712007) <br />