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Ahk 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 UST permanent 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: 430a DATE EXISTING UST DISCOVERED: 4301 I. FACILITY INFORMATION [BUSINESS ACILITY ID#(Agency Use Only) NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 BUSINESS SITE ADDRESS 103 n1 , lav S CITY 104 V-1 4r"'T I CA Ci+ IL, ANK DESCRIPTION TANK ID# 432 T 433 TTAAINX,c!ONFIGURATION: THIS TANK IS 434 �� DS O F!� '3 G' A w LSA•A STAND-ALONE TANK Vq f �IN A COMPARTMENTED UNIT. DATE UST SYSTEM INSTALLS 435 TANK CAPACITY IN GALLONS 436 CNUMBER OF TMfbr each Iin the NTS INTHEUNIT 431 6 III.TANK USE AND;CONZENTS TANK USE OR 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): 439a CONTENTS PETROLEUM: ❑_, la REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ ib.PREMIUM UNLEADED 440 gli'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). 4401 IV::TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL [!r2-.DOUBLE WALL ❑ 95.UNKNOWN 4.43 PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.0THER (S ci ): 444a SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE 0 95.UNKNOWN ❑99.OTHER(S ec' ): 445a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS El 2.BALL FLOAT W53.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-WALLED .DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(ax3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL 1514.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 9A.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL W 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4641 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑2.DOUBLE WALL ❑ 90.NONE 4644 L VENT,VAPOR RECOVERY`(VR)"AND'RISER9 FILLPIPE PIPING CONSTRUCTION" VENT PRIMARY CONTAINMENT ❑ 1.STEEL Fkr4.FIBERGLASS U 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 4Me1 ❑ 90.NONE ❑ 99 .OTHER(Specify) 464f VR PRIMARY CONTAINMENT ❑ 1.STEEL 21.FIBERGLASS464fl ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑-99.OTHER(Specify) 4648 VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.R1GID PLASTIC ❑ 90.NONE El99.OTHER(Specify) 4464h VENT PIPING TRANSTTION SUMP TYPE0 1.SINGLE WALL WfDOUBLE WALL 0 90.NONE 464hl 4641 RISER PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE Lj 99.OTHER(Specify) 4" RISER SECONDARY CONTAINMENT 1.STEEL El 4.FIBERGLASS ❑ 10.RIGIDPLASTIC d 90.NONE 99.OTHER S ecifY) 464k FILL COMPONENTS INSTALLED 1.SPILL BUCKET ❑ 3.STRIKER PLATEBOTTOM PROTECTOR .CONTAINMENT SUMP 4 64kll VII.UNDER DISPENSER CONTAINMENT.(UDC),. CONSTRUCTION TYPE1.SINGLE WALL LJ 2.DOUBLE WALL ❑ 3.NO DISPENSERS 1190.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696 c VIIL. CORROSIONPROTECTION STEEL COMPONENT PROTECTION Ll 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 legal requirements. APPLICANT SIGNATURE DATE f � ' if 420. APPLICANT NAME(print) 471' APPLICANT TITLE 1 iM�N >CE412. t 2>0 UPCF UST-B-1/2 a Rev.(12/2007) L 4.,.