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' R UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form A�RO 13 TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and S I I IV,anti IX below) 430 ❑ 1..NEW PERMIT r.�3.RENEWAL PERMIT6-8. CHAN ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE [ 1 8.UST REMOVAI TAL HUA DATF.UST PERMANENTLY CLOSED: "'a DATE EXISTING UST DISCOVERED: M I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 BUSTNESS NAME(Same as FACILI NAME or DBA-Doing Business As) 3 fC BUSINESS SITE ADDRESS 1113 1 -7 ` � CITY )04 II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: Tli1S TANK IS 434 [TI.A STAND-ALONE TANK. [12.ONE IN A COMPARTMENTED UNIT. Complete me Me for each cm tient in tM uniL DATE UST SYSj M�TALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 433 [,T III.TANK USE AND CONTENTS TANK USE }R la.MOTOR VEHICLE FUELING [I lb.MARINA FUELING ❑ lc.AVIATION FUELING 439 (� 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used oil) ❑ 5,EMERGENCY GENERATOR FUEL[HSC§25281.5(,)] ❑ 6.OTHER GENERATOR FUEL. ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROL.EUw� la.REGULAR UNLEADED ❑ 1c.MIDGRADE UNI-EARED ❑ lb.PREMIUM UNLEADED 440 /'. 3.DIESEL. ❑ S.JET FUEL ❑ 6.AVIATION GAS C. ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROI.FUM(Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ L SINGLE WALL 2.DOIJBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL [ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S cci 444a •n �r)� SECONDARY CONTAINMENT ❑ I.STEEL FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER _.____-- ❑ 90.NONE 95.UNKNOWN ❑ 7.JACKF;TED 445 ❑99.OTLifiR S i ): 445a OVERFILL PREVENTION 1.AUDIBLE..&VISUAL ALARMS 0 2.BALL FLOAT ❑ 3.FILL TUBE SHLTr-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLF-WALLED .DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[2.3 CCR§2636(;K3)) 458 PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 4Ma SECONDARY CONTAINMENT ❑ I_STEEL [;IAFIBERGLASS ❑ S.FLEXIBLE ❑ t0.RIGID PLASTIC 464b ❑ 90.NONE I.1 95.UNKNOWN ❑ 99.OTHER(Specify): 464e PIPING/TURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2_DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE Q 99.OILIER(specify) 464, 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC Gr 90.NONE 0 99.OTHER(Specify) 464f 464ft VR PRIMARY CONIAINMBNCEl 1.SIT-EL FIBERGLASS ❑ 10.RIGIDPI.ASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464g t VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC C*90.NONE 0 99.01I1ER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 0 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 464i. RISER PRIMARY CONTAINMENT 4 1.STEEL ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC El 90.NONE 13 99.OTHER(Specify) 4641 RISER SECONDARY CONTAINM'F14T ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 09.OTHER(Specify) 464k 464kI 1,11..1,COMPONENTS_INSTALLED -l_SPILL BUCKET .STRIKER PLATE/B07TOM PROTECTOR EYA.CONTAINMENT SUMP 451 a-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE .SINGLE WALL _ ❑ 2.DOUBLE WALL. ❑ 3.NO DISPENSERS [390.NONE 469a CONSTRUCTION MATERIAL 1,STEEL 4.FIBERGLASS ❑ 10.RIGID HASITC ❑ 99.OTHER(Specify) 469t- VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES) ❑ 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 with legal requirements. APPLICANT SIG E DATE / / 470. APPLICANT N ME{pri J 471 APPLICANT TV)-E 472. UPCF UST-B-1/2 Rev.(12/2007)