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Qj Ask AM ` XWFIED PROGRAM CONSOLIDATED FO1W UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (OneformperUST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections I,11,111,IV,and 1Xbelow) azo. ❑ 1.NEW PERMIT W3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4308 I DATE EXISTING UST DISCOVERED: 1"Oh I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 14/1 LL BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) BUSINESS SITE ADDRESS 103. 1 CITY 104 II. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 43,4 -76% .A STAND-ALONE TANK Complete one page for each �✓u ❑ 2.ONE IN A COMPARTMENTED UNIT compartment in the unit. DATE UST SYSTE NSTALLED 435• TANK CAPACITY IN GALLONS 436• NUMBER OF COMPARTMENTS IN THE UNIT 437. oUd � III. TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ 1c.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 ❑ 95.UNKNOWN ❑ 99._OTHER(Specify): 4398_ CONTENTS PETROLEUM: W 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): 440x. _........_. ...................- -- NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL DOUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT ❑ 1.STEEL FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTE AL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4448 SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. [190.NONE ❑ 95.UNKNOWN [199.OTHER(Speci 4458. OVERFILL PREVENTION AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 45 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVE L REVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL jjF.DOUBLE WALL ❑ 99.OTHER 460. SYSTEM TYPE 1.PRESSURE [3'2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458. PRIMARY CONTAINMENT ❑ 1.STEEL yjg�.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464x. SECONDARY CONTAINMENT ❑ 1.STEELFIBERGLASS [3 &FLEXIBLE ❑ 10.RIGID PLASTIC 464b. [190.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 4644 VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [3 99.OTHER(Specify): g64el_ VENT SECONDARY CONTAINMENT [11.STEEL .FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [399.OTHER(Specify): 464ff�. VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): a644g. VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [1 1. (Specify): 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL .DOUBLE WALL ❑ 90.NONE 464J. RISER PRIMARY CONTAINMENT- STEEL -X4.FIBERGLASS ❑ 10.RIGID PLASTIC [390.NONE [399.OTHER(Specify): 464il. RISER SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS El 10.RIGID PLASTIC [190.NONE [199.OTHER(Specify): 464ki. FILL COMPONENTS INSTALLED SPILL BUCKET STRIKER PLATE/BOTTOM PROTECTOR _A.CONTAINMENT SUMP 45la-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 4698 CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify fiuttIthis UST system is compatible with the hazardous substance stored and that the information provided herein is true, accuratK an4 in full compBance with le al requirements. APPLICANT SIGNATUR DATE 470. APPLICANT NAME(print) / •C 1. APPLICANT TITLE C` 472. UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org J