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UNIFIED PROGRAM CONSOLIDATED FORM k2V J110 UNDERGROUND STORAGE TANK !l qct 4(p %)v OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST 1 LYPPOF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,[I,III,IV,and IX below) 430 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION El 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 41 DATE EXISTING UST DISCO 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ U � _ � 1 BUSINESS NAME Same as FACILITY NAME or DBA-Doing Busi ess As) 3 BUSINESS SITE ADDRESS 103 LA N 6 CITY C� r-j loo IL TANK ESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 . ` I L;'f.A STAND-ALONE TANK J Y�S [12.ONE IN A COMPARTMENTED UNIT. Complete one page for each cmnpament in the mt. DATE UST SYSTEM INSTALLE 435 TANK APACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 III.TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(lndudes Used Oil ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHERS OTHER(Specify): 439. CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED S11b.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 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 Q 1. INGLE WALL EY2.DOUBLEWALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT .STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER444a SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS [3 (S 6.EXTERIOR MEMBRANE LINER 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify) 445a OVERFILL PREVENTION 0--LAUDIBLE&VISUAL ALARMS 2.BALL FLOAT FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PROD! /WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED N2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE .PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(.x3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL DAF FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL EK FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 9 UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE RYL SINGLE WALL ❑2.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECOVER (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENTU 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL U 4.FIBERGLASS 10.RIGID PLASTIC 7490.NONE U 99.OTHER(Specify) 464E 464A VR PRIMARY CONTAINMENT ❑ 1.STEEL JZ4.FIBERGLASS 11 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 4648 VR SECONDARY CONTAINMENT ❑ 1.STEEL U 4.FIBERGLASS ❑ 10.RIGID PLASTIC .NONE 0 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPEEl 1.SINGLE WALL 0 2.DOUBLE WALL NV.NONE 4641. RISER PRIMARY CONTAINMENT .STEEL 0 4.FIBERGLASS U 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENTEl 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464k 464kl FILL COMPONENTS INSTALLED Erl.SPILLBUCKET Er3.STRIKER PLATE/BOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 451&c /VIL UNDER DISPENSER CONTAINMENT WDQ CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2. UBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469. CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS 0.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE - CERTIFICATION: 1 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. APPLICANT SIGNATURE VA DATE 470. APPLICANT NAME(print) 471. APPLICANT TITLE 472. UPCF UST-B-1/2 `" vRev.(12/2007)