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Cl /2y/��) <br /> UNIFIED PROGRAM CONSOL XO <br /> UNDERGROUND STORAG Imo' <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) <br /> TYPE OF ACTION (Check one item only. Fora cloatre or removal,complete only this section and Sections 1.If.III.II,and IX below) 430. <br /> ❑ 1.NEW PERMIT 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: 430& 1 DATE EXISTING UST DISCOVERED: 430b. <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) t <br /> BUS SS NAME lSame as Fac'ity Name or DBA-Doing Business.-is) 3. <br /> BUSINESS SITE T> e -7 -7 c'f, nn��G_l4 fQ crnr s4F C'FL-c-r'-n C r?- C1 104. <br /> II. TANK DESCRIPTION <br /> TANK I^D# 932• TANK MANUFACTURER 433. T FIGURATION:THIS TANK IS 434. <br /> 1 / V x &P � �. . eqM-A Coui;A to one page for ewh <br /> Tr�� ONE IN A COMPARTMENTED UNIT comPeeronrnt in the unit. <br /> DATE UST SYSTEM INSTALLED_ 435. TANK CAPACITY IN GALLONS 436- NUMBER OF COMPARTMENTS IN THE UNIT 417 <br /> III. TANK USE AND CONTENTS <br /> TANK USE OTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc.AVIATION FUELING 439• <br /> ff'3.CHEMICAL PRODUCT STORAGE ❑4.HAZARDOUS WASTE(btdwa Used Oil) ❑ 5.EMERgPICY GENERATOR FUEL[HSC§25281.5(c)] <br /> ❑ 6.OTHER GENERATOR FUEL ❑95.UNKNOWN ❑ 99. ER(Specify): 439& <br /> CONTENT,y�g) PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED CK&PREMIUM UNLEADED 440. <br /> 1 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑8.PETROLEUM BLEND FUEL ❑9.OTHER PETROLEUM(Specify): 440a <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ lo.ETHANOL <br /> ❑ <br /> 11.OTHER NON-PETROLEUM(Specify): 440b <br /> IV.,TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL DOUBLE WALL ❑ 95.UNKNOWN 443 <br /> PRIMARY CONTAINMENT ❑ L STEEL FIBERGLASS ❑ 6.INTERNAL BLADDER 444. <br /> _ ❑ 7.STEEL+INTERNAL LIG [195.UNKNOWN ❑ 99.OTHER(Specify): 444& <br /> SECONDARY CONTAINMENT ❑ 1.STEEL r0o E LASS ❑6.EXTERIOR MEMBRANE LINE El 7.JACKETED 445. <br /> ❑ 90.NONE _ ❑ 95.UNKNOWN (399.OTHER(Specify): 445x. <br /> OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT CkT FILL TUBE SHUT-OFF VALVE 452. <br /> 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT ASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑ 1 ---__SE WALL .DOUBLE WALL ❑ 99.OTHER 460• <br /> SYSTEM TYPE M4.-PRESSURE ❑ 2. ❑3.CONVENTIONAL SUCTION ❑4.SAFE SUCTION(23 CCR 02636(ax3)] 458. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL EPCFIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464• <br /> _ ❑ 90.NONE ❑ 95.LINKNOWN 99.OTHER(Specify): 464& <br /> SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464b. <br /> ❑ 90.NONE ❑ 95.UNKNOWN 99.OTHER(Specify): 464c <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 4644 <br /> VI. VENT,VAPOR RECOVERY )AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL 4.FJJBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 446W- <br /> 64e1 <br /> VENT SECONDARY CONTAINMENT ❑ I.STEEL GLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑99.OTHER(Specify): 4664 <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL 4 BERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4464g. <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.R PLASTIC [190.NONE ❑ 99.OTHER(Specify): q`4641t. <br /> 464h <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL .110UBLE WALL ❑ 90.NONE <br /> 464i. <br /> RISER PRIMARY CONTAINMENT LKSTEEL ❑4.VE&RGLASS ❑ 1&RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): q j. <br /> RISER SECONDARY CONTAINMENT ❑ 1.S 4.FIBERGLASS 10.RIGID PLASTIC [390.NONE [199.0 R(Specify): 464k <br /> 464k1. <br /> FILL COMPONENTS INSTALLED_ la4SPILL BUCKET . TRIKER PLATE/BOTTOM PROTECTOR CONTAINMENT SUMP 451a-c. <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ❑ 1.SINGLE WALL DOUBLE WALL ❑ 3.NO DISPENSERS ❑90.NONE 469& <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT .ISOLATION 448, <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: 1 eet this UST system is compatible with the hazardous substance stored and that the information provided herein is true, <br /> accu t an full c3Mtiance with legal requirements. <br /> APPLICANT SIGNATU --- DATE a <br /> 470 <br /> APPLICANT NAME(print) r� L 1 Cc7 APPLICANT TITLE 47' <br /> UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org <br />