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2F_1.1/nom l -,T -A )a UNIFIED PROGRAM CONSOLIDATED FOIkM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (One form per UST) ❑ L NEW PERMIT El 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION TYPE OF ACTION (Check one item only. For an UST permanent closure or removal, complete only this section and Sections 1, 11, 111, IV, and IX belo WOTL4 ❑ 6. TEMPORARY UST CLOSURE El 7. UST PERMANENT CLOSURE ON SITE ® 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: '30a DATE EXISTING UST DISCOVERED: 9/1/2013 30b I. FACILITY INFORMATION 3 FACILITY 1D # (Agency Use Only) - -1 1 1-2- I I BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) 3 Levand Family Trust BUSINESS SITE ADDRESS 103 47 East Eleventh Street 1 CITY 104 Trac II. TANK DESCRIPTION TANK ID # 1 432 -rA OC TANK MANUFACTURER 433 Unknown TANK CONFIGURATION: THIS TANK IS 434 N I. A STAND-ALONE TANK F12. ONE IN A COMPARTMENTED UNIT. Complete one page for each com anment in the mit. DATE UST SYSTEM INSTALLED 475 unknown TANK CAPACITY IN GALLONS 436 500 NUMBER OF COMPARTMENTS IN THE UNIT 437 1 III. TANK USE AND CONTENTS TANK USE ❑ la. MOTOR VEHICLE FUELING C1lb. MARINA FUELING El lc. AVIATION FUELING 439 Ll3. CHEMICAL PRODUCT STORAGE El 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 5. EMERGENCY GENERATOR FUEL [HSC §25281.5(c)] ❑ 6. OTHER GENERATOR FUEL ® 95. UNKNOWN ❑ 99. OTHER (Specify): 439. CONTENTS PETROLEUM: ❑ la. REGULAR UNLEADED ❑ lc. MIDGRADE- UNLEADED ❑ lb. PREMIUM UNLEADED 440 ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (Specify): unknown petroleum 440i NON -PETROLEUM ❑ 7. USED OIL ❑ 10. ETHANOL ❑ 11. OTHER NON -PETROLEUM (Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 2. DOUBLE WALL N 95. UNKNOWN 443 PRIMARY CONTAINMENT ❑ I_ STEEL ❑ 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 ❑ 7. STEEL+ INTERNAL LINING N 95. UNKNOWN ❑ 99. OTHER (Specify): 444. SECONDARY CONTAINMENT ❑ L STEEL [13. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445 ❑ 90. NONE N 95. UNKNOWN ❑ 99 OTHER (Specify): 445. 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 -WALLED [12. DOUBLE -WALLED N 99. OTHER 460 SYSTEM TYPE ❑ I. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR §2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ L STEEL ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER(Specify): 464. SECONDARY CONTAINMENT ❑ L STEEL ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464b ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464c PIP[NGfrURBINE CONTAINMENT SUMP TYPE ❑ I. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE 464d VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ L STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE N 99. OTHER (Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE N 99. OTHER (Specify) 464f 464A VR PRIMARY CONTAINMENT ❑ L STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE N 99. OTHER (Specify) 464; MASI VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE N 99. OTHER (Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE ❑ 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE 4641. RISER PRIMARY CONTAINMENT ❑ I. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE N 99. OTHER (Specify) 464j 464j I RISER SECONDARY CONTAINMENT ❑ I. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE N 99. OTHER (Specify) 464k 464k1 FILL COMPONENTS INSTALLED ❑ I. SPILL BUCKET ❑ 3. STRIKER PLATEIBOTTOM PROTECTOR ❑ 4. CONTAINMENT SUMP 45 1., VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE N I. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 469. CONSTRUCTION MATERIAL N 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 IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, aecar#tj;' and in full compliance with legal requirements. APPLICANT SIGNATURE DATE 9/20/2013 .470. APPLICANT NAME (print) Ro ert Marty 471. APPLICANT TITLE Agent for Levand Property Trust 472. UPCF UST -B - 1/2 Rev. (I2 A