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UNIFIED PROGRAM CONSOLIDATED FORM 9/3 UNDERGROUND STORAGE TANK 7 v5 OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only skis section and Sections L A 111,11;and IX belott) 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: 43oa 1 DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) - - („' I. BUSINESS AME(Same a F c.1.0.Name or D A-Doing BI S'tens As) 3. I ' , ' BliSIN SS SITE ADDRES 03 BUSINESS ITE CITY 104. 2 C� II. TANK DESCRIPTION TANK ID- = ANK MA��erleo'-A UFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. ❑ 1.A STAND-ALONE TANK Complete one page for each W2.ONE IN A COMPARTMENTED UNIT compartment in the mit. DATE UST S TEM INSTALLED j( 435- TANK CAPACIT IN GALLONS 436- NUMBER OF COMPARTMENTS IN THE UNIT 437. Q III. TANK USE AND CONTENTS TANK USE get..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 125281.5(c)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED I11b.PREMIUvi UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM_BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406. IV. TANK CONSTRUCTION TYPE OF TANK_ _❑ 1.SINGLE WALL ff'52.DOUBLE WALL ❑ 95.UNKNOIVN _ 443. PRIMARY CONTAINMENT ® L STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 44C ❑ 7.STEEL-INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): tea_ SONDARY'CONTAINMENT ❑ L STEEL �3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. EC _ ❑ 90.NONE_ ❑ 95.UNKNOWN El99.OTHER(Specify): 445a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ® 3.FILL TUBE SHUT-OFF VALVE 45' ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION 41. 11 PIPING CONSTRUCTION ❑ 1.SINGLE WALL Iff 2.DOUBLE WALL ❑ 99.OTHER SYSTEM TYPE 1.PRESSURE ® 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(aN3)] 458 PRIMARY CONTAINMENT ❑ L STEEL 0 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a 1 SECONDARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS [38.FLEXIBLE ❑ I O.RIGID PLASTIC 4646. ❑ 90.NONE C] 95.UNKNOWN [3464c.99,OTHER(Specify): 464d PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION a64e ; VENT PRIMARY CONTAINMENT 5T.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464e1. 464E J VENT SECONDARY CONTAINMENT [R1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): q�O, VR PRIMARY CONTAINMENT �L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464 1 - -- 464h VR SECONDARY CONTAINMENT &�L STEEL ❑ 4.FIBERGLASS �DOUBLE 90.NONE ❑ 99.OTHER(Specify): 464ht. -- - VENT PIPING TRANSITION SUMP TYPE ❑ L SINGLE WALL 90.NONE RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464j RISER SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464kt FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUNIP 4?tac VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE art.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a --- - ------ - - - 4696. CONSTRUCTION MATERIAL [el.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) r.;W VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate and In fUll compliance with legalr uirements. APPLICANT SIGNATURE DATE VV� s7o. APPLICANT NAME(print 4 GE 471. APPLICANT -' TITLE 4 UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org Effective 01/17108 f