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UNIFIED PROGRAM CONSOLIDATED FORM a, UNDERGROUND STORAGE TANK , 2 I I� 1 OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) tt) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,I1,III,IV,and IX below) 430 I.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: 431 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) FftO l _�q'- _ _ I BUSINESS NAME(Same as FACILITY NAME or DBA- Doing Business As) 3 Sa C BUSINESS SITE ADDRESS 103 CITY 104 Il.TANK DESCRIPTION TANK ID# 43'- I TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 D�1 g�� ❑1.A STAND-ALONE TANK 2.ONE IN A COMPARTMENTED UNIT. 3111,445 Complete one page for each compartment in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 14000 Z. III.TANK USE AND CONTENTS TANK USE ;d I a.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ 1c.AVIATION FUELING 439 ❑ CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used oil ❑ 5.EMERGENCY GENERATOR FUEL IHSC§25281.5(c)I ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: M.la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S i : 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT CS 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT B 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S eci ): 445a OVERFILL PREVENTION UL 1.AUDIBLE&VISUAL ALARMS CK 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 IN 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(a)(3)I 458 PRIMARY CONTAINMENT ❑ 1.STEEL Nt 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL UL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ I.SINGLE WALL R 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 ff 90.NONE ❑ 99.OTHER(Specify) 464e 464e I VENT SECONDARY CONTAINMENT ❑ 1.STEEL M 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 46417 46417 VR PRIMARY CONTAINMENT ❑ 1.STEEL K 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 4640 VR SECONDARY CONTAINMENT ❑ 1.STEEL li&4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL2.DOUBLE WALL ❑ 90.NONE 464i. RISER PRIMARY CONTAINMENT 9 1.STEEL [14.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 464'I RISER SECONDARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641, 4641,1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTONI PROTECTOR N 4.CONTAINMENT SUMP 451 a-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL 1C 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL g 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bbc 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, and in full compliance with legal requirements. APPLICA SIGNA UR DATE 470 CA APPLICANT NAME(print) 471 A PLICANT TITLE 472 UPCF LIST-B-1/2 Rev.(12/2007)