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trIFFIED PROGRAM CONSOLIDATED FO _ Lj <br /> UNDERGROUND STORAGE TANK I/�j 7-7 3o U g <br /> 111;OPERATING PERMIT APPLICATION-TANK INFORMATI N ( e rm usr) <br /> VTYP <br /> FACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11,111,IV,and IX below) 430. <br /> 1.NEW PERMIT ❑ 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: 430a DATE EXISTING UST DISCOVERED: 430b. <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) ' I. <br /> BUSINESS NAME(Same as Facility Name or D A-Doing Business As) 3. <br /> �L <br /> BUS NESS SITE As-RESS� l�V ^ 103 CITY 04 <br /> C, �V <br /> II. TANK DESCRIPTION <br /> TANK ID# 432. TANK MANUFACTURER 433• 'T.A�NK CONFIGURATION:THIS TANK IS 434• <br /> Q 11p t.A STAND-ALONE TANK Complete one page for each <br /> O� ( j� �% �� ❑ 2.ONE INA COMPARTMENTED UNIT compartment in the unit. <br /> DATE UST SYSTEM INSTALLED 435. TANK C PA ITY ISI GALLONS 436• NUMBER OF COMPARTMENTS IN THE UNIT 437• <br /> - <br /> III. TAN USE AND CONTENTS <br /> TANK USE Unj la.MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ Ic.AVIATION FUELING 439. <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] <br /> ❑ <br /> 6.OTHER GENERAT R FUEL ❑ 95.UNKNOWN [3 99.OTHER(Specify): 439& <br /> CONTENTS PETROLEUM: la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ 1b.PREMIUM UNLEADED 440. <br /> C] 3.DIESEL C35.JET FUEL ❑ 6.AVIATION GAS <br /> C] 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440x. <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ <br /> 11.OTHER NON-PETROLEUM(Specify): 440b. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL E3153.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444& <br /> SECONDARY CONTAINMENT ❑ 1.STEEL Lpf FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445& <br /> OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT LEr 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 ❑ l SINGLE WALL trl DOUBLE WALL ❑ 99.OTHER 460. <br /> SYSTEM TYPE Q51.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL Q4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. <br /> ❑ 90.NONE [125.UNKNOWN ❑ 99.OTHER(Specify): 464x. <br /> SECONDARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. <br /> _ ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL CY2.DOUBLE WALL ❑ 90.NONE 4644 <br /> VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS [1l0.RIGID PLASTIC ❑ 90.NONE [399.OTHER(Specify): 4664eel. <br /> VENT SECONDARY CONTAINMENT [11.STEEL QI.FIBERGLASS ❑ 10.RIGID PLASTIC [390.NONE [:199.OTHER(Specify): 464f. <br /> 464f1. <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL lEf4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): gbg8. <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464h. <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 464i. <br /> RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS [110.RIGID PLASTIC [390.NONE [199.OTHER(Specify): 4644. <br /> RISER SECONDARY CONTAINMENT ❑ I.STEEL [a<FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46441. <br /> FILL COMPONENTS INSTALLED j2rf.SPILL BUCKET Zj73.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 451a-c. <br /> VII. UNDER DISPENSER CONTAINMENT (UDC) <br /> CONSTRUCTION TYPE ❑ L SINGLE WALL 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE' 469& <br /> 469b. <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL Q4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c. <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT6.ISOLATION 44S, <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, <br /> accurate and in full om liance with le al requirements. <br /> APPLICANT SIGNATURE DATE 470. <br /> APPLICANT NAME(print) Jel u� 471. APPLICANT TITLEbaup 472. <br /> UPCF UST-B Rev.(12/200')-1/2 l�T www.unidocs.org <br />