BILLING PRE 2019 - Laserfiche WebLink

Home Browse Search

ED PROGRAM CONSOLIDATED FO UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. Fora UST closure or removal, complete only this section and Sections Ill, Ill, N, and IX below) 430. ❑ 1. NEW PERMIT ❑ 3. RENEWAL PERMIT ® 5. CHANGE OF INFORMATION ❑ 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a. I DATE EXISTING UST DISCOVERED: 430h I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) _ O O O _ 1. BUSINESS NAME (Same as Facility Name or DBA - Doing Business As) 3. 7 -Eleven #19976 BUSINESS SITE ADDRESS 103. CITY 104. 1399 N. Main ST. 1 Mantenca II. TANK DESCRIPTION TANK ID #7�1'SiS� g'7 432• TANK MANUFACTURER 433. TANK CONFIGURATION: THIS TANK IS 434. 001 Xerxes ® 1. A STAND-ALONE TANK Complete one page for each ❑ 2. ONE IN A COMPARTMENTED UNIT compartment in the unit. DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436• NUMBER OF COMPARTMENTS IN THE UNIT 437. 6/2003 15,000 III. TANK USE AND CONTENTS TANK USE ® la. MOTOR VEHICLE FUELING ❑ ]b. MARINA FUELING ❑ lc. AVIATION FUELING 439. ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (includes Used Oil) ❑ 5. EMERGENCY GENERATOR FUEL (HSC §25281.5(c)] _❑ 6. OTHER -GENERATOR FUEL [395. UNKNOWN ❑ 99. OTHER (Specify): 439a. _ _ CONTENTS PETROLEUM: - ® la. REGULAR UNLEADED mm❑ lc. MIDGRADE UNLEADED ❑ ]b. PREMIUM UNLEADED 440• ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (Specify) 440a. _.__.......... ._................. NON -PETROLEUM: ❑ 7. USED OIL - -_ ❑ 10. ETHANOL ❑ 11. OTHER NON -PETROLEUM (Specify): IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ® 2. DOUBLE WALL ❑ 95. UNKNOWN 443. --..............................................._...._._....__..__......_......-.._....................._-_....__._._............ __......_......................._.... ..... ---......_........................--.... _....................---...........................................................................................--..--............_.._........................-........................................................................ PRIMARY CONTAINMENT ❑ 1. STEEL ® 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444. _ _ ❑ 7. STEEL+ INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 444x. ---._ ... -_ ... --- -- -............................................ ........ ............... .......- -- SECONDARY CONTAINMENT ❑ 1. STEEL ®3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445 _ _❑ 90. NONE ❑ 95. UNKNOWN 99. OTHER_ (Specify): 445a. _ _❑ OVERFILL PREVENTION ❑ 1. AUDIBLE & VISUAL ALARMS ❑ 2. BALL FLOAT �- ® 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 WALL ® 2. DOUBLE WALL ❑ 99. OTHER 460• ..........................."""" _ ..._.._._.._...__.._........................._......._....... __.............................._..._....__..._._..- ....---...._..---. ........ SYSTEM TYPE 1. PRESSURE ❑ 2.. GRAVITY ❑ 3_CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION (23 CCR §2636(a)(3)] 458. - - _-® - PRIMARY CONTAINMENT ❑ L STEEL ❑ 4. FIBERGLASS ® & FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOW_ N ❑ 99. OTHER (Specify): 464a. SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS -- -® & FLEXIBLE '_.__...__......... ❑ 10. RIGID PLASTIC NONE-_.._._.._.._._ 95. UNKNOWN OTHER city): 464c. 464c. __............__._......._......._. _. -0.90_ ....................0..99, PIPING/TURBINE 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 ❑ 1. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 4�• ......................................................................_....................................................................._.._..........._.................................._....._.._..................._.__._......-..........._....-------..__.._...- ..... _.-_............_ . _._. 464e1. VENT SECONDARY CONTAINMENT ❑ I. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC N90. NONE ❑ 99. OTHER (Specify ): 464f. 464f1. VR PRIMARY CONTAINMENT ❑ L STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 4Mg' ........... -.---.......................... _............................._._..........--------...._.........------........_.._........._.............._......_..........._.."__....................................................................._.... 4b!E 1.:...... VR SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ® 90. NONE ❑ 99. OTHER (Specify): 46441. VENT PIPING TRANSITION SUMP TYPE ® 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE 4M'' ........... .............. ........................ _.... _............. ....__ _ .-...............I...---......- ---- .... __-_._........... ................ _..... _.......... _................... _-.-......... ..._._.._..........................................._.._...... .............. __............. ...._-...._._-.._.........._...... _...... __... ........ .............. -.... ._......... _.._...----............. __ RISER PRIMARY CONTAINMENT ❑ L STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 464j: .-............_.................-....__.-..._.� - -----......._...._......_........................................................_......---..........................._.._._-......----....._............... __...-_"..."-_. ..___L _. RISER SECONDARY CONTAINMENT . . . ......... .... ............ . ....................... ...... .... ............................. 4 - FILL COMPONENTS INSTALLED ® 1. SPILL BUCKET ® 3. STRIKER PLATE/BOTTOM PROTECTOR ❑ 4. CONI A INMENT SUMP 451a -c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 469a. ........................._.._.................................................................................__..................................................-------...._.............._.................._..._._........... CONSTRUCTION MATERIAL ❑ 1. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 469b. 469c. 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 SIGNATURE �/ DATE iL/�0 470 N n APPLICANT NAME (print) Ian Moorhead 471.APPLICANT TITLE - nV. COrriphance Mgr. 472 .,d UPCF UST -B Rev. (1212007) - 1/2 www.unidocs.org