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0 9 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) JYRE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,11,Ill,IV,and IX below) 430 1.NEW PERMIT [13.RENEWAL PERMIT ❑ S.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE Q 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4308 DATE EXISTING UST DISCOVERED: 4306 1. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 U BSINESS SITE ADDRESS 101 CITY 100 - - _ - - anf II.TANK DESCRIPTION TANK ID# 432 SANK MANUFACTURER 433 TA K CONFIGURATION:THIS TANK IS 434 ��® (°W(1 wi rn e n.,,�• 1.A STAND-ALONE TANK tAL '2_((fI u� .ONE IN A COMPARTMENTED UNIT. Com otx tbreachc tin the,miL DATE UST SY EM INSTALLED 435 TANK AP CITY 1 GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT oae 437 III.TANK USE AND CONTENTS TANK USE Cl la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc_AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Imludm Lh dOil) �EMERGENCY GENERATOR FUEL[HSC§25281.5(c)]0 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑99.OTHER(Specify): 439a CONTENTS PETROLEUM: .�❑ 7la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 I'�.DIESEL ❑ 5.JET FUEL [36.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM eci : 440a NON-PETROLEUM: 7.USED OIL [j10.ETHANOL ❑ l 1.OTHER NON-PETROLEUM(S(Specify)- 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL 3t 2.DOUBLE WALL ❑95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ I.STEEL A3.FIBERGLASS ❑6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑95.UNKNOWN ❑ 99.OTHER (S if): 4448 SECONDARY CONTAINMENT ❑ 1.STEEL W.FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑90.NONE ❑95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS MI 2.BALL FLOAT ❑3.FILL TUBE SHUT-OFF VALVE 452. 4.TANK MEETS REQUIREMENTS IrOg EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑L SINGLE WALLED DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE1.PRESSURE [32.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3 458 t PRIMARY CONTAINMENT ❑ I.STEEL ❑4.FIBERGLASS ❑ 8.FLEXIBLE 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4648 SECONDARY CONTAINMENT ❑ 1.STEEL ❑4.FIBERGLASS ❑S.FLEXIBLE 10.RIGID PLASTIC 464b ❑ 90.NONE ❑95-UNKNOWN ❑99.OTHER(S cify): 464c j PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 464d 1 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 1.STE: 4.FIBERGLASS 10.RIGID PLASTIC ❑90.NONE L3 99.OTHER(Specify) 464e 4 Act 13 VENT SECONDARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464F as4n VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS (310.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4649 - 464 I VR SECONDARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ L SINGLE WALL 2.DOUBLE WALL 90.NONE 4644 RISER PRIMARY CONTAINMENT L STEEL [14.FIBERGLASS 10.RIGID PLASTIC ❑90.NONE 99.OTHER(Specify) 4641 461'1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 0 3.STRIKER PLATEIROTTOM PROTECTOR ❑4.CONTAINMENT SUMP 45[a-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ L SINGLE WALL 2.DOUBLE WALL ❑3.NO DISPENSERS ❑ 90.NONE 4698 CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ l0.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑4.IMPRESSED CURRENT ❑&ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided herein Is true,accurate, and in lull compliance with legal requirements. APPLICANT SIGNATURE elp. cB (a DATE �E.�7/� /�( 470,A NA th CVP(1 °f/`vlAj,R,^ 471. APPLICANT �I '+ 872. UPCF UST-B-1/2 Rev.(12/2007)