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AIAL UNIFIED PROGRAM CONSOLIDATED FORM -31 Q 1- UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 430 ❑ 1.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 L FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 BUSINESS NAME(Sas FACILITY NAME or DBA-Doing Business As) �" FT 3 a BUS SS UM ADDRESS �^ LA AJ 103 CITY Tac�� toa 1 II TANK'DESCRIPTIt ON TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 $.ASTAND-ALONE TANK ln� ❑2.ONE IN A COMPARTMENTED UNIT. C✓ Conwlaw one pay for each cwwarunft in the uniL DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 om ffi.TANK USE AND CONTENTS' TANK USE a.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439 13 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: la.REGULAR UNLEADED [3 1c.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 3.DIESEL ❑ 5.JET FUEL E36.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b IV.,TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑95.UNKNOWN 443 PRIMARY CONTAINMENTL STEEL [13.FIBERGLASS r_16.INTERNAL BLADDER 444 7.STEEL+INTERNAL LINING [195.UNKNOWN ❑ 99.OTHER (S ): 444a SECONDARY CONTAINMENT ❑ L STEEL UU.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S )• 445a OVERFILL PREVENTION KI.AUDIBLE&VISUAL ALARMS CJ 2.BALL FLOAT 1&3.FILL TUBE SHUT-OFF VALVE 452. ❑4.TANK MEETS REQUIREMENTS Fun EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/_WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE I.PRESSURE ❑2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(ax3)] 458 PRIMARY CONTAINMENT 1.STEEL �$ FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 1390.NONE (]95.UNKNOWN ❑99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL jjbC FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/fURBINE CONTAINMENT SUMP TYPE X 1.SINGLE WALL ❑2.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL.PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 L STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGH)PLASTIC b 90.NONE ❑ 99.OTHER(Specify) 464f 464fl VR PRIMARY CONTAINMENT 1.STEEL �4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑90.NONE 99.OTHER(Specify) 464g 46421 VR SECONDARY CONTAINMENT ❑ 1.STEEL j,4.FIBERGLASS 10.RIGID PLASTIC AL.90.NONE 0 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL 20 90.NONE 464L RISER PRIMARY CONTAINMENT WI.STEEL4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464j 464.1 RISER SECONDARY CONTAINMENT I.STEEL `.FIBERGLASS F,10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464k 464kl FILL COMPONENTS INSTALLED It 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 45la•c VII.UNDER DISPENSER CONTAINMENT(UDC). ' CONSTRUCTION TYPE 1.SINGLE WALL ❑2.DOUBLE WALL [13.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL 1.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 tbA this UST system is compatible with the hazardous substance stored and that the information providedherein is true,accurate, and in lolvC41111pliance with lexal reanlrements. APPLICANT SIGNATU DATE 470. APPLICANT NAME(print) 471' APPLICANT TITLE 472 UPCF UST-B-1/2 Rev.(12/2007)