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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK 6v` <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (one form per UST) <br /> TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 111,III,IV,and IX below) 430. <br /> ❑ 1.NEW PERMIT [a 3.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) _ ►• <br /> BU SS AN4E(Same as Faci ity Name or DBA-Doing Business As) 3w <br /> BUSINESS SITE <br /> REi� SSS n `7 `7�fl M 8 R�G14 1N CITY S-f-o� C 19- 104. <br /> ^-� II. TANK DESCRIPTION <br /> TANK ID# 432• TANK MANUFACTURER 433. TAN FIGURATION:THIS TANK IS 434. <br /> -`� QI �7 x 0-P,6 Y Complete one page for each <br /> f ,` .ONE IN A COMPARTMENTED UNIT compartment in the unit. <br /> DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. <br /> III. TANK USE AND CONTENTS <br /> TANK USEP.W.-MOTOR VEHICLE FUELING ❑ I b.MARINA FUELING ❑ t c.AVIATION FUELING 439. <br /> LT 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(includes Used Oil) ❑ 5.EMERG GENERATOR FUEL[HSC§25281.5(c)] <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99. ER(Specify): 439& <br /> CONTENb PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED b.PREMIUM UNLEADED 440. <br /> C?1j��yry- ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> y [18.PETROLEUM BLEND FUEL [39.OTHER PETROLEUM(Specify): 440a. <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ l 1.OTHER NON-PETROLEUM(Specify): 4406. <br /> IV.,TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL UBLE WALL ❑ 95.UNKNOWN 443. <br /> PRIMARY CONTAINMENT ❑ I.STEELFIBS GLASS ❑ 6.INTERNAL BLADDER 444. <br /> [37.STEEL+INTERNAL LIKG ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444& <br /> SECONDARY CONTAINMENT ❑ 1.STEEL FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINES ❑ 7.JACKETED 445. <br /> 1390.NONE [395.UNKNOWN [399.OTHER(Specify): � 445& <br /> OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT .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.S _E WALL 2.DOUBLE WALL ❑ 99.OTHER 460. <br /> SYSTEM TYPE PRESSURE ❑ 2. ❑3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(ax3)] 458. <br /> PRIMARY CONTAINMENT ❑ L STEEL 047FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. <br /> ❑ 90.NONE ❑ 95.LRfKNOWN 99.OTHER(Specify): 464& <br /> SECONDARY CONTAINMENT ❑ 1.STEEL E14.-FIBERGLASS 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. <br /> ❑ 90.NONE ❑ 95.UNKNOWN 99.OTHER(Specify): 464a <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 464d <br /> VI. VENT,VAPOR RECOVERY )AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL 4.F E GLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464el <br /> VENT SECONDARY CONTAINMENT [31.STEEL GLASS [310.RIGID PLASTIC [390.NONE El99.OTHER(Specify): 464E <br /> 464Fl. <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL 4 ERGLASS ❑ 10.RIGID PLASTIC ❑90.NONE ❑ 99.OTHER(Specify): q46 g <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.NCWPLASTIC [190.NONE ❑ 99.OTHER(Specify): g460 <br /> -- 46411. <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL DOUBLE WALL [390.NONE <br /> RISER PRIMARY CONTAINMENT .STEEL ❑ 4.F RGLASS ❑ 10.RIGID PLASTIC [390.NONE E399.OTHER(Specify): qM i_ <br /> RISER SECONDARY CONTAINMENT ❑ I.PE11 OalFIBERGLASS 0.RIGID PLASTIC ❑ 90.NONE ❑ 9 464L <br /> jjJER(Specify): <br /> g <br /> FILL COMPONENTS INSTALLED la--.SPILL BUCKET TRIKER PLATE/BOTTOM PROTECTOR .CONTAINMENT SUMP 451a•c. <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ❑ I.SINGLE WALL DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469& <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL .FBERGLASS ❑ l0.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b. <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ISOLATION 448. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I cert' t this UST system is compatible with the hazardous substance stored and that the information provided herein is true, <br /> accu to an -In full co liance with legal requirements. <br /> APPLICANT SIGNATU DATE GL © 470. <br /> �APPLICANTNAME(print) t-.t) A- Lig -TT- A- A)&T MAPPLICANT TITLE 472. <br /> UPCF UST-B Rev.(12/2007)-1/2 www.unidoes.org <br />