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�i UNIFIED PROGRAM CONSOLIDATED FORM 16 )j i7 UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UsT) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,UI,N,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: "i DATE EXISTING UST DISCOVERED: 43M I. FACHATY INFORMATION FACILITY ID#(agency Use Only) 19 S BUSINESS NAME Same as FACILITY NAME or DBA-Doing Busin As) s v�� BUSINE SITE ADSS m � f, 103 CICY / sa4 II.TANK DESCRIPTION TANK ID# p p 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 A STAND-ALONE TANK J� 2.ONE IN A COMPARTMENTED UNIT. Ide owe Me for each compartnmm is We unit DATE UST SYSTEM INS ALLED 435 TANK _ ALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 i� bon ) USE AND CONTENTS TANK USEla.MOTOR VEHICLE FUELING ❑ ib.MARINA FUELING ❑ 1c.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.IIAT..ARDOUS WASTE(lwclW s UsedOi) ❑ 5.EMERGENCY GENERATOR FUEL[HSC¢3281.5(c)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHERS OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED lb.PREMIUM UNLEADEV 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 ❑ I I.OTHER NON-PETROLEUM(specify): 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL %Z.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ L STEEL V&3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION 1.AUDIBLE.&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 45L ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.S`lNGLE-WALLED W.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ba 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 73 CCR§2636(ax3)) 458 PRIMARY CONTAINMENT ❑ 1.STEEL 1&4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTIER(Specify): 464a SECONDARY CONTAINMENT 01, 1.STEEL 1&4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL tv 2.DOUBLE WALL ❑ 90.NONE 4644 VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT M 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT V 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464E 464fl VR PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464 i VR SECONDARY CONTAINMENT is 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 4641 RISER PRIMARY CONTAINMENT i.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464j 464if RISER SECONDARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99-OTHER(Specify) 464k kt 64 FILL COMPONENTS INSTALLED I.SPILL BUCKET ❑ 3.STRIKER PLATEIBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 4 464 l VII.UNDER DISPENSER CONTAINMENT"C} CONSTRUCTION TYPE ❑ 1.SINGLE WALL (92.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) rea _.xr 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION 10 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" to ie,accurate, and in full compliance w'th legal requirements. APPLICANT SIGNATURE DATE D ` l 470. APPLICANT NAME(print) a7s. APPLICANTTITLE 47_ �o `r � ��r}. �� d� m y UPCF UST-B-112 Rev.(12/2007)