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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPRIZATINC. 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, 11,111, IV, and IX below) 430 ❑ L NEW PERMIT ❑ 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) _ I BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) L0 i d Jy epw �� 1 �^ f 3 �V��rrl('�I I �(� [ BUSINESS SITE ADDRESS � (s` -Fo w i o nt jJ.� I ` 1 �1 �r 11 CCI�T�Y 104 i I1. TANK DDESCRIPTIONV TANK ID # 432 '} TANK MANUFACTURER 433 A K CONFIGURATION: THIS TANK IS 434 �� ASTAND-pLONfiTANK E IN A CPARTMENTED UNIT. 1 02 ON OM Com tele one a for each rnm anmenl in rhe unit. DATE UST SYSTEM INSTALLED r7 435 1 LONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 TANK CAPACITY N GALLONS 2-0,000 nt,' 1I1. TANK USE AND CONTENTS TANK USE ❑ 16. MOTOR VEHICLE FUELING ❑ ib. MARINA FUELING lc. AVIATION FUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Includes Used Oil) S. EMERGENCY GENERATOR FUEL [HSC §25231.5(01 ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN 99. OTHER (Specify); 439a CONTENTS PETROLEUM: ❑ la. REGULAR UNLEADED ❑ lc. MIDGRADE UNLEADED ❑ ib. PREMIUM UNLEADED 4ao 3. DIESEL ❑ S. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM S eci : 440a NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ❑ 44db 11. OTHER NON -PETROLEUM (Specify); IV. TANK CONSTRUCTION TYPE OF TANK ❑ I. SIN�LL DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT ❑ I. STEFIBERGLASS ❑ 6. INTERNAL BLADDER 444 ❑ 7. STEINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1. STEEL 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER 7. JACKETED 445 1390. NONE 95. UNKNOWN ❑ 99. OTHER (Specify) 445a OVERFILL PREVENTION ❑ I. AUDIBLE & VISUAL ALARMS ❑ 2. BALL FLOAT 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 . UOUBLE-WALLED [199. OTHER 460 SYSTEM TYPE 4M I. PRESSURE ❑ 2. RAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR 12636(a)(3)1 453 PRIMARY CONTAINMENT ❑ 1. STEEL 04. FIBERGLASS ❑ $. FLEXIBLE ❑ l0. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1. STEEL ,j4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464b ❑ 90. NONE [395. UNKNOWN OTHER (Specify): 464° PIPINGffURBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL DOUBLE WALL ❑ 90. NONE 464d VI. VENT, VAPOR RECOVERY (VR) AND RISER I FILL PIPE PIPING CONSTRUCTION 1799. VENT PRIMARY CONTAINMENT ].STEEL 0 4. FIBERGLASS 0 10. RIGID PLASTIC ❑ 90. NONE OTHER (Specify)1 ,p 1 464e t.! T 1 4640 VENT SECONDARY CONTAINMENT ❑ I. STEEL ❑ 4. FIBERGLASS 10. RIGID PLASTIC r3 90. NONE 9.OTHER(Specify) 4641' awn VR PRIMARY CONTAINMENT ❑ [.STEEL ❑ 4. FIBERGLASS 10. RIGID PLASTIC ❑ 90. NONE M 99. OTHER (Specify) 464g464 1 VR SECONDARY CONTAINMENT L STEEL 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONEOTHER (Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ I. SINGLE WALL ❑ 2. DOUBLE WALL 90. NONE 4641 RISER PRIMARY CONTAINMENT ❑ L STEEL 4. FIBERGLASS ❑ W. RIGID PLASTIC ❑ 90. NONE 09.OTHER (Specify) 464i 464'1 RISER SECONDARY CONTAI MENT ❑ I. STEEL 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE W99. OTHER (Specify) 464k 464ki FILL COMPONENTS INSTALLED I. SPILL BUCKET 3. STRIKER PLATE/BOTTOM PROTECTOR ❑ 4. CONTAINMENT SUMP 451a -c VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ❑ 1. SINGLE WALL W2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 469a CONSTRUCTION MATERIAL ❑ L STEEL LX4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 469t•c I Vlll. CORROSION PROTECTION STEEL COMPONENT PROTECTION_ [32. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT 6. ISOLATION 44s. 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 SIGNATURE ala, DATE APPLICANT NAME (print) 471. APPLICANT TITLE 472 UPCF UST -B - I/2 Rev. (12/2007)