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UNIFIED PROGRAM CONSOLIDATED FORM / l <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) <br /> 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 <br /> ❑ 1.NEW PERMIT ❑ 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: 4304 DATE EXISTING UST DISCOVERED: 4306 <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) 1 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 <br /> C Gam' (n <br /> BUSINESS SITE ADDRESS /2 aul �, r Do <br /> 103 CITYI UC l� l() v� 104 <br /> H.TANK DESCRIPTION h <br /> TANK ID# R 432 TANK <br /> MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 <br /> �A oJ1r' rJ6�-8 / I ��� S NK <br /> ,�.ONE IN A COMPART1.A STAND-ALONE MENTED UNIT. <br /> Complete one page for each compartment in the writ. <br /> DATE UST SYS EIV STALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMP NTS IN THE UNIT an <br /> Ff 0 0-0 <br /> III.TANK USE AND CONTENTS <br /> TANK USE la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Ic.AVIATION FUELING 439 <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHERS <br /> OTHER(Specify): 4394 <br /> CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ 1 b.PREMIUM UNLEADED 440 <br /> 03.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUM(Specify): 440b <br /> IV. TANK.CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL 4%2.DOUBLE WALL ❑ 95.UNKNOWN 443 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL JQ.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S c' 444a <br /> SECONDARY CONTAINMENT ❑ L STEEL FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a <br /> OVERFILL PREVENTION U I.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑1.SINGLE-WALLED2.DOUBLE-WALLED ❑99.OTHER 460 <br /> SYSTEM TYPE R 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458 <br /> PRIMARY CONTAINMENT ❑ L STEEL 0'4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL 4ff 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c <br /> PIPINGfrURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 <br /> VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS l0.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 464e <br /> 464el <br /> VENT SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 464f <br /> 464Fl <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 464g <br /> 464 1 <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h <br /> 464h1 <br /> VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 4641. <br /> RISER PRIMARY CONTAINMENT PpL STEEL 4.FIBERGLASS U 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464j <br /> 464ill <br /> RISER SECONDARY CONTAINMENT 0 1.STEEL Ia 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 464k <br /> 464kl <br /> FILL COMPONENTS INSTALLED 0 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR Z 4.CONTAINMENT SUMP 451a-c <br /> VII.UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE SINGLE WALL '2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a <br /> CONSTRUCTION MATERIAL ❑ I.STEEL 4.FIBERGLASS Ll 10.RIGID PLASTIC ❑ 99.OTHER(-Specify) 4696 c <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) [14.IMPRESSED CURRENT 6.ISOLATION 448. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, <br /> and in full compUmw w th 1 al requirements. <br /> APPLICANT SIGNATURE DATE C) ry ` // 470. <br /> APPLICANT NAME(print) 471' APPLICANT TITLE J / 47'-. <br /> UPCF UST-11-112 <br /> V� _��..II�tOOdd���� <br />