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IED PROGRAM CONSOLIDATED FO UNDERGROUND STORAGE TANK r OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 4 A!!L IV 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: 430& 1 DATE EXISTING UST DISCOVERED: l;Ob. I. FACILITY INFORMATI N FACILITY ID#(Agency Use Only) USIESS NAME(Same as Facility Name or DBA-Doing Business As) U)A::&� (0 6 tqtj BUS SS SITE ADDRESS 103• CITY 104. H. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433, TANK CONFIGURATION:THIS TANK IS 434. �A D s t s7(� l�S �ffQ.A STAND-ALONE TANK Complete one page for each ❑ 2.ONE IN A COMPARTMENTED UNIT compartment in the unit. DATE UST SYSTEM I STALLED 435• TANK CAPACITY IN GALLONS 436• NUMBER OF COMPARTMENTS IN THE UNIT 437. III. TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.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): 439x. CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED L211b.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL Ll 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440a. - - ---- - - -- .......... NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406. 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+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444& SECONDARY CONTAINMENT ❑ 1.STEEL Ar.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER(Specify): 445x. OVERFILL PREVENTION ❑ 1.AUDIBLE 8c VISUAL ALARMS ❑ 2.BALL FLOAT 3.FULL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL REVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ LS WALL 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 1.STEELFIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464x. SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. _❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALLW.DOUBLE WALL ❑ 90.NONE 464(1 VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 10.RIGID PLASTIC [:190.NONE [199.OTHER(Specify): 46 e1. VENT SECONDARY CONTAINMENT [31.STEEL Xe4.FIBERGLASS [310.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46644f1. VR PRIMARY CONTAINMENT [31.STEEL *4.FIBERGLASS ❑ 10.RIGID PLASTIC [190.NONE [399.OTHER(Specify): 4�g. VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464hh . VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL .DOUBLE WALL ❑ 90.NONE tet' 4641. RISER PRIMARY CONTAINMENT I.STEEL .2-14.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464.1. RISER SECONDARY CONTAINMENT ❑ I.STEEL FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [199.OTHER(Specify): 4�j . . FILL COMPONENTS INSTALLED SPILL BUCKET .STRIKER PLATE/BOTTOM PROTECTOR CONTAINMENT SUMP 451a-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ❑ I.SINGLE WALL DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469& CONSTRUCTION MATERIAL ❑ 1.STEEL FIBERGLASS ❑ 10.RIGID PLASTIC [399.OTHER(Specify) 4696. X. 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,end in full compliance with le al requirements. APPLICANT S[GNATUR DATE i 470. APPLICANT NAME(print) 471. APPLICANT TITLE �w 47'_. UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org