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UNIFIED PROGRAM CONSOLIDATED FORM - UNDERGROUND STORAGE TAr I vel NK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) asa TYPE OF ACTION (Check one item only. For a UST 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: 430& 1 DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) - - 1 BUS DJESNAME fSqme as Facility N me or DBA-Doing Busi s As) 3. BUSINr5S SITE ADDSS 103. BUSINESS SITE CITY 104• �. t c -, II. TANK DESCRIPTION TANK ID# 437. ANK ACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. r Ia 1.A STAND-ALONE TANK Complete one page for each 4 Picky ❑ 2.ONE INA COMPARTMENTED UNIT cmnpammt in the unit. DATE UST SYSTEM INAL ED 435• TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. /ygy 12- III. TANK USE AND CONTENTS TANK USE IS--1 a.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439. ❑ 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): 439& CONTENTS PETROLEUM: J4 la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440& 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 CONTAINMENT E L STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444& SECONDARY CONTAINMENT ❑ L STEEL B 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Sped : 445a OVERFILL PREVENTION ❑ 1.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 WALL ® 2.DOUBLE WALL ❑ 99.OTHER 460. SYSTEM TYPE 1.PRESSURE W2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR§2636(ax3)] 458. PRIMARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464& SECONDARY CONTAINMENT ❑ 1.STEEL ®4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 4644 VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPfNG CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464et. VENT SECONDARY CONTAINMENT IfI.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC X 90.NONE ❑ 99.OTHER(Specify): 464fl. VR PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [199.OTHER(Specify): 4642464 664 B. VR SECONDARY CONTAINMENT I.STEEL [34.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): Ohl. l. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL r_12.DOUBLE WALL 90.NONE ---- - ------------ - - RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC [3464j.90.NONE ❑ 99.OTHER(Specify): 464'1. RISER SECONDARY CONTAINMENT 1.STEE 4.FIBERGLASS ❑ 10.RIGID PLASTIC V4 90.NONE ❑ 99.OTHER(Specify): 464kl. FILL COMPONENTS INSTALLEDI.SPILL.,,,.ET 3.STRIKER PLATEwTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a-a VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE Or 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469& CONSTRUCTION MATERIAL L STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4469bc VIII. CORROSION PROTECTION Y STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION DL APPLICANT SIGNATURE ' CERTIFICATION: I certify that this UST system Is compatible with the hazardous substance stored and that the information provided herein is'v accurate and in full compliance with Legal requirements. APPLICANT SIGNATURE DATE / X470. APPLICANT NAME(print) K 471' APPLICANT TITLE (/ a UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org Efiective 01/17