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00 • 9 UNIFIED PROGRAM CONSOLIDATED FORM /� UNDERGROUND STORAGE TANK V OPERATING PERMIT APPLICATION-TANK INFORMATIO orm 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: 410, DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY[D#(Agency Use Only) 0 - IDI 0 10 14A 1 12-11 BUSINESS NA E(Same as FACILITY NAME or DBA-Doing Business As) 3 f') u BUSINESS SITE ADDRESS 103 1 CITY 104 �- II.TANK DESCRIPTION Tt1? CyQ#O 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 ❑1.A STAND-ALONE TANK t Rc2.ONE IN A COMPARTMENTED UNIT. lete one page for each compartment in the unit. DATE UST SYSTEM INSTALLEd 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 C 311.TANK USE AND CONTENTS TANK USE &)a.MOTOR VEHICLE FUELING E] 1b.MARINA FUELING [31c.AVIATION FUELING 439 (] 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ S.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 [I Ib.PREMIUM UNLEADED 440 L� 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 4411a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL X2.DOUBLEWALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ($I.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT L STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 90.NONE ❑ 95.UNKNOWN [199.OTHER(Specify): 445a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT 19 3.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(a)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL �4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464f 464H VR PRIMARY CONTAINMENT ❑ 1.STEEL A 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL A 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4641. RISER PRIMARY CONTAINMENT ❑ 1.STEEL A 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 464i 1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC [,i�90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 0,3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE .SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469. CONSTRUCTION MATERIAL ❑ L STEEL jg�4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696-c VIIL CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT J3 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 herefifils true,accurate, and in full compliance with legal requirements. APPLICANT SIGNATURE , ` p DATE !, 1 470. APPLICANT NAME(print) 1 471. APPLICANT TITLE P tf�� 472. UPCF UST-B-1/2 Ilev.(12/2007)