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RECEIVEL UNIFIED PROGRAM CONSOLIDATED FORM MAR p8i8 UNDERGROUND STORAGE TANK LVJBQNMENTAL OPERATING PERMIT APPLICATION-TANK INFORMATIO TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,II,III, and IX below) 430 1.NEW PERMIT ® 3.RENEWAL PERMIT El 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE Q 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4302 DATE EXISTING UST DISCOVERED: 43 I FACILITY INFORMATION FACILITY ID#(Agency Use Only) 77 BUSINESS NAME(Same as FACILITYyA��oyp�Doing Business As) ��/ �� /�/O�F/ IT 3 BUSIN S SirDgAESS _ _ 103 1 CITY C - 71 , ,104 &d 5Z jZkoQ II TANKAESCRIPTI,ON, TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 �Ef�r A STAND-ALONE TANK V [:12.ONE IN A COMPARTMENTED UNIT. Com lete one a for each com artment in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAP _-ITY IN GALLONS 436 NUMBER OF/OMPARTME TS IN THE UNIT 437 d�� :. II,I.TANK.USE;AND CONTENTS; , TANK USE la.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 ❑ 95.UNKNOWN ❑ 99.OTHERS eci ( P fY): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.)ET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL0 9.OTHER PETROLEUM (Specify): ,VX;V674),J aaoa NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b G0N4TRUCTION, TYPE OF TANK 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAMMENT �Je1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S ecif): 444a SECONDARY CONTAINMENT ❑ L STEEL [13.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify) It'_10110 L' 445a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS El 2.BALL FLOAT 6 3.FILL TUBE SHUT-OFF VALVE l ,I�£ 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT /f/Gvv P,.RODUCT%WASTE PIPING CONSTRUCTION; IO PIPING CONSTRUCTN ❑1.SINGLE-WALLED E]2.DOUBLE-WALLED 199.OTHER �I/�� 46D- SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR§2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ t.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 - PRIMARY NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 41t2v 464a SECONDARY CONTAINMENT ❑ t.STEEL, ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 eM'90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 464d VL VENT;VAPOR`RECOVEBY(VR)-AND RISER"%FILL PIPE:PIPING CONSTRUCTION IBE VENT PRIMARY CONTAINMENT 1.STEEL ❑ 4.FRGLASS E] 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0.NONE ❑ 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC90.NONE ❑ 99.OTHER(Specify) 4648 464g] VR SECONDARY CONTAINMENT [11.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC o.NONE ❑ 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE 0 L SINGLE WALL ❑ 2.DOUBLE WALL 37TO.NONE 4641. RISER PRIMARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC90.NONE [:199.OTHER(Specify) 464j 464'I RISER SECONDARY CONTAINMENT L STEEL 4.FIBERGLASS 10.RIGID PLASTIC .FV90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET 3.STRIKER PLATEIBOTTOM PROTECTOR 4.CONTAINMENT SUMP 45la-c VII ;UND.ER DISPENSER,C.ONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS 0.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) sl/' 469b-c VIiI:.,GURROSIONPRQTECTION: ; . 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 co n with legal pqgicoments. APPLICANT SIGNATU470. A DATE APPLICANT NAME(print) 471' APPLICANT YITLLA 472. UPCF UST-B-1/2 Rev.(12/2007)