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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. For�an,�ST permanent closure or removal,complete only this section and Sections I,II,III,IV,and D{below) 430 ❑ 1.NEW PERMIT CV3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 43oa DATE EXISTING UST DISCOVERED: 4306 L FACILITY INFORMATION' FACILITY ID#(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 SU Piz S-m-P , BUSINESS SITE ADDRESS l03 Z� 14,r� 16+ ��- CrrY�A�ti� CA- �/S33L I°' II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TA CONFIGURATION:THIS TANK IS 434 Ing SHld/L WA STAND-ALONE TANK ❑2.ONE IN A COMPARTMENTED UNIT. Co etc one Pw for each cmparmiaa in the urk DATE USTEMS STALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPAR NTS IN THE UNIT 437 c C:G Ca III.TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.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): 439a CONTENTS PETROLEUM: a.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ lb.PREMIUM 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 . TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.,POUBLE WALL ❑95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ L STEEL .F ERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL WING ❑95.UNKNOWN ❑99.OTHER (S ): 444a SECONDARY CONTAINMENT 131.S EL 3.FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 13 NONE El95.UNKNOWN ❑99.OTHER(Specify) 445a OVERFILL PREVENTION I or 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. ❑4.TANK MEETS REQUIREMENTS F R EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V PROD_UC)FIVAM PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED On.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE .PRESSURE ❑2. RAV ITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(ax3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑95 OWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL FBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4641 ❑ 90.NONE ❑ 95.UNKNOWN ❑U THER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL UK.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPORRECOVE (VR)AND RISER/FILL.PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT El 1.STEEL rW4 FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE U 99.OTHER(Specify) 464e VENT SECONDARY CONTAINMENT 13 L STEEL 4 IBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.0THER(Specify) 464f 464fl VR PRIMARY CONTAINMENT ❑ 1.STEEL 4 FIBERGLASS ❑ 10.RIGID PLASTIC ❑90.NONE 99.OTHER(Specify) 4648 VR SECONDARY CONTAINMENT 464 1 ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 464L RISER PRIMARY CONTAINMENT L STEEL 4.FIBERGLASS 0 10.RIGIDPLASTIC 0 90.NONE 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT 1. EL13 4.FIBERGLASS G 10.RIGID PLASTIC 0 90.NONE In 99.OTHER(Specify) 464k 464kl FILL COMPONENTS INSTALLED Lirl.SPILL BUCKET 0 3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER.C NTAINMENT,(UDC). CONSTRUCTION TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL C FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696c VIIL 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 lexalrequirements. APPLICANT SIGNATURE DATE , / O azo. APPLICANT NAME(print) 411' APPLICANT T t/1 an. �t�t,laA-R.D c,A-2 A �R V"I f�l�U, UPCF UST-B-1/2 Rev.(12/2007)