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• 00 UNIFIED PROGRAM CONSOLIDATED FORM u ( 3 UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATI 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: 430. 1 DATE EXISTING UST DISCOVERED: 430b 1. FACILITY INFORMATION FACILITY ID#(Agency Use Only) -P _ _ I BUSINE NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 (r')U ' v o 'G BUSINESS SITE ADDRESS 103 1 CITY ro 104 II._TANK DESCRIPTION T &#0 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 �f ❑1.A STAND-ALONE TANK .9 2.ONE IN A COMPARTMENTED UNIT. tete 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 III.TANK USE AND CONTENTS TANK USE 6 la.MOTOR VEHICLE FUELING ❑ 1b.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 ❑ lb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS 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 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT L STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ L STEEL [13.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 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 Pg 2.DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.URAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(.)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464f 46411 VR PRIMARY CONTAINMENT ❑ 1.STEEL rV A.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 4640 VR SECONDARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT ❑ I.STEEL4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 R 4641 RISER SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATEBOTTOM PROTECTOR 4.CONTAINMENT SUMP 45la-c VII',UNDEA DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ZL 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL J5L 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696-c VIII. CORROSION PROTECTION '= STEEL COMPONENT PROTECTION [12.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION m;. 449. IX. APPLICANT SIGNATURE b� CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,arsgturate, and in full compliance with legal requirements. APPLICANT SIGNATURE - DATE 7 r 470. APPLICANT NAME(print) 471. APPLICANT TITLE 1 ✓ 472. 0, UPCF UST-13-1/2 Rev.(12/2007)