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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,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 0 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 43011 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(,Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Dom Business As) 3 c=X,v4e c=ss )2K T 7 (� BUSINES SITE DRESS , - 103 CITY 104 r U TN /YIA /Aj S i R-�E ln�/I/' L L" IL TANK DESCRIPTION TANK ID# 2 432 TANK MANUFACTURER 433 4,3J3� TANK CONFIGURATION: THIS TANK IS 434 tJ/ y 33c� C 9 W "�a.P�At ❑2.ONE M STAND-ALONE COMPARTMENTED UNIT. D�` C to one far each in the unit DATE UST SY T M INSTALLEDL,(A M 35 TANK CAPACITY M GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 % U O;)U D.TANK USE AND CONTENTS TANK USE Is.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)) ❑ 6.OTHER GENERATOR FUEL [:195.UNKNOWN El99.OTHER (Specify): 4392 CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 R 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 4402 NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 11.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL IK2.DOUBLEWALL 0 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ L STEEL 3.FIBERGLASS 6.INTERNAL BLADDER 444 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Sc' ): 444a SECONDARY CONTAINMENT ❑ I.STEEL 23 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Speci445a OVERFILL PREVENTION Q I.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 6 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 ❑2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR§2636(#3)j 458 PRIMARY CONTAINMENT OR I.STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 0 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT L STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT L STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 464r 464n VR PRIMARY CONTAINMENT U I.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 4648 464XI VR SECONDARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90,NONE 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 0 L SINGLE WALL 2.DOUBLE WALL 90.NONE 464i. RISER PRIMARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT 0 L STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED I.SPILL BUCKET 0 3.STRIKER PLATEIBOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 451a-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ L STEEL 0 4.FIBERGLASS 0 10.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: 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 withlegal requirements. APPLICANT SIGNATURE / y)/Le__F (� DATE /O 1� �j 470 / A rTp��ME(print) 471. APPLICANT TITLE 472. l)LJl S. i� Crr�`r �)�) � UPCF UST-B-1/2 Rev.(12/2007)