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L4�o5 UNIFIED PROGRAM CONSOLIDATED FORM 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 1,II,III,IV,and IX below) 430 1.NEW PERMIT ❑ 3.RENEWAL PERMIT [15.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) I BUS SS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 Dto MaIL-y- BUSINESSS E RESS03 CITY 104 U.TANK DESCRIPTION TANK ID# - ��]O 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 /7 [11.A STAND-ALONE TANK �J U F2.ONE INA COMPARTMENTED UNIT. tete one page for each campwtmft in the umt. DATE UST S TEM RZTALLED 435 TANK AP Q ITY IN GALLONS 436 NUMBER OF COMPA$TMENTS IN THE UNIT 437 !j/ ui.TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includa Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED Ib.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 S eci ): 440b IV..TANK:CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL Id 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL P 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTER AL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Sci ): 444a SECONDARY CONTAINMENT ❑ 1.STEEL FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.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 OVERF LL PREVENTION EQUIPMENT V.. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE [1'2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR U636(a)(3)] 458 PRIMARY CONTAINMENT M 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGiTURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR REC RY(VR)AND R/FELL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 464ff VR PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 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 0 4.FIBERGLASS ❑ 10.RIGID PLA C90.❑ 90.NONE 9,❑ OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT 0 I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE El 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 00LSPILL BUCKET 0 3.STRIKER PLATE/BOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 451a-c VII.UNDER DISPENSER ONTAINMENT.(UDC) CONSTRUCTION TYPE 1.SINGLE WW 2.DOUBLE WALL [13.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4691-c L 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 cokopliance with legal ruirements. APPLICANT SIGNATURE DATE " 470. 7 LL APPLICANT NAME(print) 471' APPLICANT TIT,�,E ,o- " 472• UPCF UST-B-112r,v 1�" Rev.(12/2007)