BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

• UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK 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 L 11.Ill.IV,and DC helow) 430- 0 1-NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL 43ob. DATE UST PERMANENTLY CLOSED: 4I- ING DATE EXISTUST DISCOVERED: I. FACILITY INFORMATION 1. FACILITY ID#(Agency Use Only) - - - BUSINESS N E(Saes Facility Name or DBA-Doing Business As) 3. Ct BUSINESS SITE ADDRESS 103 CITY c r.,��pN� C C{ ' Z-{ 104" -7- fy'&-(21 (nzs� II. TANK DESCRIPTION 433. 434- TANK ID# 43- TANK MANUFACTURER TANK C NFIGURATION:THIS TANK IS ❑ 1 STAND-ALONE TANK Complete one page for each f F i } /` 2.ONE IN A COMPARTMENTED UNIT eoniPgancnt in the unit. DATE ST SYSTEM INSTALLED_ 435- TANK CAPACITY IN GALLONS 436- NUMBER OF COMPARTMENTS IN THE UNIT 437. '7 C-C--f) r�-- III. TANK USE AND CONTENTS TANK USE a-MOTOR VEHICLE FUELING ❑ lb-MARINA FUELING ElIc.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5-EMERGENCY GENERATOR FUEL[HSC,125281.5(c)) ❑ 6-OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 9. CONTENTS PETROLEUM: ❑ Ij..REGULAR UNLEADED El 1c.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440. \ .DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS 11-f l ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): NON-PETROLEUM:❑ 7.USED OIL ❑ 10-E I7 WNOL C] 11.OTHER NON-PETROLEUM(Specify): IV ANK CONSTRUCTION TYPE OF TANK_ ❑ I.SINGLE WALL BLE WALL ❑ 95.UNKNOWN_ _ _ 443' PRIMARY CONTAINMENT ❑ L STEEL ffff.FIBERGLASS ❑ 6.INTERNAL BLADDER ' ❑ 7.STEEL+INTERNAL L G ❑ 95-UNKNOWN ❑ 99.OTHER(Specify): 444a SECONDARY CONTAINMENT ❑ L STEEL -FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER [17.JACKETED 445. [390-NONE [3 95_UNKNOWN ❑99.OTHER(Specify): 4JSa - OVERFEVEION E] 1.AUDIBLE&VISUAL ALARMS [I2.BALL FLOAT LLTFIUBE SHUT-OFF VALVE 452- ILL PRNT ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT ASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ I. GLE WALL 2.DOUBLE WALL ❑ 99.OTHER -_- 458. _SYSTEM TYPE _ -PRESSURE _� 2 V�TY_ ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR 12636(ap3)] PRIMARY CONTAINMENT ❑ 1-STEEL 4-FIBERGLASS ❑ &FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE -_0 995.UN- "OWN ❑ 99.OTHER(Specify):- 464. SECONDARY CONTAINMENT ❑ I-STEEL &4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464h ❑ 90.NONE [195.UNKNOWN ❑ 99. R(Specify): 4644 PIPINGITURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL _ UBLE WALL []-90.NONE VI. VENT,VAPOR RECOVERY )AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL4.FIBERGLA55 ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): �j ---- -- FIB -- VENT SECONDARY CONTAINMENT ❑ 1-STEEL (�4. ERGLASS ❑ 10-RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464 VR PRIMARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4M. 44 VR SECONDARY CONTAINMENT ❑ 1.STEEL -FIBERGLASS ❑ l0 GID PLASTIC ❑ 90.NONE [399.OTHER(Specify): 4640hl. VENT PIPING TRANSITION SUMP TYPE ❑ 1-S GLE WALL 2-DOUBLE WALL ❑ 90.NONE 464i. RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS C] 10-RIGID PLASTIC ❑ 90.NONE 1-] 99.OTHER(Specify): 464 1 RISER SECONDARY CONTAINMENT [I S EEL -RBERGLA [I10.RIGID PLASTIC (390.NONE ❑ 99. ER(Specify): pj INM FILL COMPONENTS INSTALLED I-SPILL BUCKET 1 EY3.STRIKER PLATE(BOTTOM PROTECTOR MA4.CONTAINMENT SUMP 451a-e- VII. UNDER DISPENSER CO NT(UDC) CONSTRUCTION TYPE _❑ L SINGLE WALL _ _ _.DOUBLE WALL ❑ 3.NO DISPENSERS_ ❑ 90.NONE -__ 469�a 469bCONSTRUCTION MATERIAL ❑ I.STEEL 4.F[B.RGLASS ❑ l0-RIGID PLASTIC ❑ 99.OTHER(Specify) a69c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT SOLATION 448- 1X. APPLICANT SIGNATURE CERTIFICATION: I cert[f, this UST system is compatibk with the hamrdons substance stored and that the information provided herein is true, ad* oll compjiapce with legai uiremenm 470. APPLICANT SIGNATURE'' --� DATE a �f e APPLICANT NAME(printLlp 471' APPLICANT TITLE tU'�'�l_--- 472. UPCF UST-B Rev.(12/2007)-1/2 www-unidocs.org