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LT IFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE WANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) T�OFACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,1I,III,IV,and IX below) 430 ❑ ❑ 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: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINFLS NAME Same as FACILITY NAME or DBA-Doing Business As) 3 BUSJNFSS Tt D S 103 CITY 104 II.TANK DESCRIPTION TANK ID# �LL D��lbJ.I p TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK 1S 434 *I.A STAND-ALONE TANK 2 ONE rN A COMPARTMENTED UNIT. Co.tete one a for each corn em in the unit. DATE UST S S� M INSTALLED 435 TAN .IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 ,fJ' 111.TANK USE AIS 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: ❑ar la.REGULAR UNLEADED [3lc.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 AJ3.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(S i ): 440b IV. TANK.-CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 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 STEEL3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER [:17.JACKETED 445 C390.NONE 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION Lj 1.AUDIBLE&VISUAL ALARMS 0 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 [12.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE El 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION [14.SAFE SUCTION[23 CCR c2636(#.M 458 PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ &FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/rURBINE 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 L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 464e ❑ VENT SECONDARY CONTAINMENT ❑ 1.STEEL El 4.FIBERGLASS [:110.RIGID PLASTIC 46441 90.NONE ❑ 99.OTHER(Specify) 464f 464fl VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464g 464 1 VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT L STEEL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPIL_L_B_U_CK_E_T___ff 3.STRIKER PLATEIBOTTOM PROTECTOR 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT:(UDC) CONSTRUCTION TYPE 1.SINGLE WAL [12.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696-c VIII. 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 legal requirements. APPLICANTS NATURE DATE e - 470. -'� at'l AP" rmt) 471. APPLICANT TITLE -^ w; 472. UPCF UST-B-1/2 r" Rev.(12/2007)