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Ak A& 6 IED PROGRAM CONSOLIDATED FO q, UNDERGROUND STORAGE TANK 7-3c�- O Cif 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 11,111,IV,and 1X below) 71�4 L NEW PERMIT ❑ 3.RENEWAL PERMIT El 5.CHANGE OF INFORMATION [16.TEMPORARY UST CLOSURE El 7.UST PERMANENT CLOSURE ON SITE [18.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a• I DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ _ BUSINESS NAME(Same as Facility Name or DBA- oing Bus' ess As) J BUSINESS SITE KDDRE93103. 1 CITY iw. QA C� II. TANK DESCRIPTION TANK ID# 432• TANK MANUFACTURER 433• TAW CONFIGURATION:THIS TANK IS 434. Q11.A STAND-ALONE TANK Complete one page for each ❑ 2.ONE IN A COMPARTMENTED UNIT compartment in the unit. DATE US SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436• NUMBER OF COMPARTMENTS IN THE UNIT 437. 2d o m III. TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ Ib.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 ❑ 95.UNKNOWN ❑ 99._OTHER(Specify): 439& CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADEDb.PREMIUM UNLEADED aa0. ❑ 3.DIESEL ❑ 5.JET FUEL 96.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440a. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION TYPE OF TANK _❑ 1.SINGLE WALL %2-1.DOUBLE WALL ❑ 95.UNKNOWN _ 443• PRIMARY CONTAINMENT ❑ 1.STEEL FIBERGLASS ❑ 6.INTERNAL BLADDER • ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444& SECONDARY CONTAINMENT ❑ 1.STEEL PT FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445• _ ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445& OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT .FILL TUBE SHUT-OFF VALVE 452• ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERffl,PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE 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.STEEL W4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 9 .UNKNOWN ❑ 99.OTHER(Specify): 464& SECONDARY CONTAINMENT ❑ 1.STEEL W4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 92.OTHER(Specify)_ 4640. 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 464 VENT PRIMARY CONTAINMENT ❑ I.STEEL 4244.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464el. VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46441. VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS [310.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): q464g. VR SECONDARY CONTAINMENT ❑ 1.STEEL a4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NON ❑ 99.01'11FR(Specify): 464h. ___------._ ,.� 464h 1. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL V2.DOUBLE WALL ❑ 90.NONE 464'' _- --� RISER PRIMARY CONTAINMENT Q t•STEEL [I4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [1464J 99.OTHER(Specify): 46441 RISER SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ V. (Specify): 46441. FILL COMPONENTS INSTALLED SPILL BUCKET STRIKER PLATE/BOTTOM PROTECTOR LCr4.CONTAINMENT UMP 45la-c. VII. UNDER DISPENSER CONTAINMENT (UDC) a q CONSTRUCTION TYPE ❑ L SINGLE WALL W4DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.VON 469& CONSTRUCTION MATERIAL ❑ 1.STEEL J-2"4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c. VIII. CORROSION PROTECTION 14 j7 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 f 11 compliance with legal requirements. APPLICANT SIGNATURE DATE b b 470. APPLICANT NAME(print) ML) 471. APPLICANT TITLEI C n 472. UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org L /�