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O l UNIFIED PROGRAM CONSOLIDATED FORM ? p? 7 D UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) E 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 i.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: 430b I. FACILITY INFORMATION' FACILITY ID#(Agency Use Only) + t BUSINESS N (Same a�FACILITY NAME or DBA-Doing Business As) l 3 BUSINE S SIT RE J/a, I03 Orly 104 II.TANKDESCRIPTION TANK ID# -r4 O� i1 n 432 TANK MANUFACTURER 433 T CONFIGURATION: THIS TANK IS 434 3 STT Z/Cl/ A STAND-ALONE TANK Z.ONE IN A COMPARTMENTED UNIT. ,L Complete one pay for each compmtnent in the unit DATE UST SYSTFNLINSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 ),>Al -`III.TANK USE AND CONTENTS TANK USE Ia.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Indudes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[DISC§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 ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b IV. TANKCONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL 14 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNALLINING ❑ 95.UNKNOWN ❑ 99.OTHER (S ): 444a SECONDARY CONTAINMENT 131.STEEL 3.FIBERGLASS [16.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION 111.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT qk 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL-PREVENTION EQUIPMENT Ve PRODUCT 1 WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 01-SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 0,1.PRESSURE [:12.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(ax3)] 458 PRIMARY CONTAINMENT El 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE 95.UNKNOWN ❑99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL q1 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 464d VI:VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT U 1.STEEL ❑ 4.FIBERGLASS 11 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 4640 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑90.NONE ❑ 99.OTHER(Specify) 464f 464fl VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464, 464el VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE Q 1.SINGLE WALL 0 2.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT El 1.STEEL 4.FIBERGLASS 11 10.RIGID PLASTIC ❑90.NONE ❑ 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 451a-c VII.UNDER DISPENSER CONTAINMENT.(UII CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL, ❑ 1.STEEL a 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑99.OTHER(Specify) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑4.IMPRESSED CURRENT ❑ 6.ISOLATION 448• IX. APPLICANT SIGNATURE CERTIFICATION:I certify that this ST system is compatible with the hazardous substance stored and that the information provided herein is true,:accurate, and in full compkance with legal require nts. APPLICANT SIGNATURE DATE 470. APP ICANT NAME rint) 471. APpLIC7 ANT TITL an. UPCF UST-B-1/2 Rev.(12/2007)