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-� UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) a. TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this ection and Sections I,iI,III,IV,and IX below) ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT 'k 5.CHANGE OF INFORMATION ElZ/, ( 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE E] 8.UST REMOVAL -___ _ I C 43i 430a DATE EXISTING UST DISCOVERED: Ij DATE USTPERMANENTLY Y Ci OSED• ` i. FACILITY INFORMATION FACILITY ID#(Agency Use Only) - - 3 BUS t SS N ME(Sam! s FACILITY NAM or DB -Doi) Business As) BUSINESS SIT A D F � 103 CITY 104 , � T 1�2128'151 II.TANK DESCRIPTIONTANK 1D# 432 TANK MANUFACTURE R 433 TANK CONFIGURATION: THIS TANK is❑1..A STAND-ALONE TANK �� i 2.ONE IN A COMPARTMENTED UNITTA fete one a e for tachwm artment in the unit.DATE UST SYST;M INSTALLED 435 TANK CAPA�INGALLONS 436 NUMBER OFA PARTMENTS INTHE UNI��III.TANK USE AND CONTENTSTANK USE la.MOTOR VEHICLE FUFLING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING3.CHEMICAL PP,ODUCT,STORAGE ❑ '*.HA7ARDOUS WASTE(includes[Iced Oiq ❑ 5.EMERGENCY GENERATOR 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify):CONTENTS PETROLEUM: ❑ I..REGULAR UNLEADED ❑ toMIDGRADE UNLEADEDI h.PREMIUM UNLEADED 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (S eci NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL l� ❑ 11.OTHER NON-PETROLEUM(Specify): IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2,DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95. KNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL X3.FIBERGLASS 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.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 OVEKFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED K2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ff 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR q'2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLF ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464f 464fl VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464g 464 I VR SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALT. 90.NONE 464'. RISER PRIMARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID P:.ASTIC U 90.NONE ❑ 99.OTHER(Specify) 4641 464'1 RISER SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE E] 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATEBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT(UDC). CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696-c VIII.CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify ha t s tem is a with t hazardous substance stored and that the information provided hercm is true,accurate, and in fit an ith al requirements. 470 DATE � APPLICANT SIGNATURE o APPLICANT NAME(Print) 147t. APPLICANT TITLE 472. l.V 7�_ ,� SS 2� F 1 c�.✓ � �.t - j UPCF UST-B-1/2 Rev.(12/2007) T i,