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0 T UNIFIED PROGRAM CONSOLIDATED FORPYT ^ UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete on/r this section and Sections 1,11.111 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 El 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430& 1 DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION 1. FACILITY ID T(Agency Use Onl)) - - a BUSINESS (Same F cil'R°Name or DB - �Bluffness As BUSINES911TE ADDRESS 103 BUSINESS T)CITY IN. i^ II. TANK DESCRIPTION TANK ID 4P-. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. ❑ 1.A STAND-ALONE TANK Complete onein the fix each ,`[ ! ®2.ONE rN A COMPARTMENTED UNIT comp�tinrnt in the unit DATE UST Y TEM INSTALLED 435. TANK CAPACITZN GALLONS 436- NUMBER OF COMPARTMENTS IN THE UNIT 437. 4` l III. TANK USE AND CONTENTS lc.AVIATION FUELING 439' TANK USE ®')a.MOTOR VEHICLE FU ELING ❑ Ib.MARINA FUELING ❑ ❑ 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. 44a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL E] 4 9.OTHER PETROLEUM(Specify): __30& NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 440b. ❑ [1.OTHER NON-PETROLEUM(Specify): IV. TANK CONSTRUCTION 443. TYPE OF TANK ❑ I.SINGLE WALL la'2.DOUBLE WALL ❑ 95.UNKNOWN 444. PRIMARY CONTAINMENT Q 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER ❑ 7.STEEL-INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444& SECONDARY CONTAINMENT ❑ L STEEL ® .FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER [:] 7.JACKETED 445. 3 ❑ 90.NONE ❑ N ❑95.UNKNOW99.OTHER(Specify): 445& 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 ❑ L SINGLE WALL Iff 2.DOUBLE WALL ❑ 99-OTHER 460 SYSTEM TYPE 1.PRESSURE } 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR;2636(a1(3)] 458. 464' PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a _ SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4b-3c. 464b. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464d PIPING/PURBINE CONTAINMENT SUMP TYPE IL 1.SINGLE WALL El2.DOUBLE WALL ❑ 90.NONE VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT I.STEEL a 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 44644eej VENT SECONDARY CONTAINMENT 0 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 'Q 90.NONE ❑ 99.OTHER(Specify): 46�4fl - 464_z VR PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464 1. 464h. VR SECONDARY CONTAINMENT L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 464hl. VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE _ _. RISER PRIMARY CONTAINMENT B 1.STEEL (:14.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90 NONE ❑ 99.OTHER(Specify): 4641. RISER SECONDARY CONTAINMENT [a I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC Ik 90.NONE ❑ 99,OTHER(Specify): 464E1. FILL COMPONENTS INSTALLED 7M L SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45)a c' VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE $1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3_NO-DISPENSERS ❑ 90.NONE - 469& CONSTRUCTION MATERIAL 48 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION [12.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is tre, accurate,and in ull co I' ce with Legal requirements. APPLICAINT SIGNATURE DATE L 471. APPLICANT TITLE APPLICANT NAME(print) crl [;r 2 AHAw.unidocs.or � PCF UST-B Rev.(12/2007)-i!_ g Effective O1/17�11`t('