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dook A& U 4kaaljP <br /> IFIED PROGRAM CONSOLIDATED F01W. Wj <br /> UNDERGROUND STORAGE TANK 25� �� q <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (one form per US ) <br /> TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and SF81. <br /> ns 1,11,111,/V,and IX below) 430. <br /> C] 1.NEW PERMIT ❑ 3.RENEWAL PERMIT .CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430a. I DATE EXISTING UST DISCOVERED: 430b. <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) - - 1. <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> BUSINESS STPE A15DRESS104. <br /> 75 nl WA I v MA <br /> II. TANK DESCRIPTION <br /> TANK ID# 432. TANK M ACTUR 433. TANK CONFIGURATION:THIS TANK IS 434. <br /> ,7 1.A STAND-ALONE TANK Complete one page for each <br /> 2.ONE INA COMPARTMENTED UNIT compartment in the unit. <br /> DATE UST SYSTEM MTS?LLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPA TMENTS IN THE UNIT 43z <br /> !N0oo <br /> III. TANK USE AND CONTENTS <br /> TANK USE ]a.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439. <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a. <br /> ..........__......................__....._..-._.._..._......._.._..._._......._._....._..........................._........._......_..........._....._...................................................._.._......................................_..- -- ._...--..._..._......._..........._.......... _. <br /> CONTENTS PETROLEUM: 1 a.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ 1b.PREMIUM UNLEADED 4aU. <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM B_L_E_N_D FUEL ❑ 9.OTHER PETROLEUM(Specify): 440a. <br /> .................._..................................................._..... . . . . _.-..__..............._.._....._......................_................_._.........................-_........_... ........................................_.. <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443. <br /> -.........._..._..._.................__........................................_......_....................._....--...................__..............--..._.........._.._._._..............._._................__......__.............._....................._.........................................................................._....................aaa:.. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL X 3.FIBERGLASS ❑ 6.INTERNAL BLADDER <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444x. <br /> ....................................................................................._.........._......-....._..... _._._.....----._......._....._.........................._............................... ......._._._........_.............._..... <br /> SECONDARY CONTAINMENT ❑ 1.STEEL Pr3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a. <br /> -.._......................................._.._.......................__........_............................................................_.................................._.._......__.._._...._._._-..__........-._..__._.._._...__.................._...._._..............._.._............ 2...... <br /> OVERFILL PREVENTION ❑ 1.AUDHiLE&VISUAL ALARMS ❑ 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 99.OTHER 460. <br /> ......._....._................._......................._..................................................._..._.._...._......_...._........._._......_.................._......_......._-.._._.._.._.__._...._.........................-- -......._..........._....................---......._.._...._..........................._._............_......._........_..---.__.......__..._....-.........................._..._.............-........._......................_.......... <br /> SYSTEM TYPE1.PRESSURE El 2.GRAVITY C1 3.CONVENTIONAL SUCTION O 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458. <br /> _..._....._........__................ <br /> PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. <br /> ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464a. <br /> -.__..._...._.._...._...................__.................................................._......................_.........__............................._............._.....- ....._........._...---._._..__._........._.._._.-.........._--............._._....... <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. <br /> ❑ 90.NONE �95.UNKNOWN ❑ 99.OTHER(Specify): 464c. <br /> _................_.._..............................__........... _...._........._...- -........__.._._..__. ...__...._................_._...---....__....._........._.........._................._...................._._....................-......_..._............._ ....._......._.................._................... <br /> PIPING/IURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d. <br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): a64e1. <br /> ... ---.......--...............__._._.................._..._...._.._..._....._................._._.........._..........._......................._.............._............_........._...._......._._.._.__......_._.._._.._..........._........._.......-.....---....._.__.._....._......_............._............__.......................................... _.. .4464f <br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464E <br /> ---..........._.............................................................................._........................_......._...-...........................-....................._.._..........._.__.......................__....................._........................................-........................................-.................__.._.._.__...----......--..._.._..- -.._...._.._... <br /> 464g. <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4641- <br /> .. .. .......---. ......................._..........--.................................-.........................._......._.._.._........_......_............_........_........_.__...._._._._._............................-----._._._. _. 464h. <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464h1 <br /> _. ............---._..............._........................._..._...................................._.........._...................._.._......._...._.__......................._....__.._...__...____._.._.._............_.........._....................................._...................._................................._....._....................._..._......_.._._-_.-_...__..... ... . <br /> VENT PIPING TRANSITION SUMP TYPE E] 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE464i <br /> --._..._..................._...--...._.........................................................................._........._..........__..._.._..-....._..........._........_........._.....__..........._...................---............................_....................._...-....................................................._.......................... <br /> RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC C] 90.NONE ❑ 99.OTHER(Specify): g46j1. <br /> RISER SECONDARY CONTAINMENT ❑... 1.STEEL ❑ 4.FBERG SS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99 OTHER(Specify): 46641. <br /> _......_..............................-- -.._...._...._.....-..............__..__..._..... _..._.._.__..__......_.....__._......-.-.-----......._------..........._.._..._.............._..........._......................_...................._..... ..... <br /> FILL COMPONENTS INSTALLED ].SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a-c. <br /> . UNDER DISAENSER CONTAINMENT (UDC) <br /> CONSTRUCTION TYPE 1.SINGLE WALL 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a. <br /> _........................................................................................_..._.._.._..__......- -..._....._..._....................._..........._.........._......................................................_................_...__..............._....._........._....._......_....-_........__...._.....__....._......---._......_...._....._..........._.........._......................._......... <br /> CONSTRUCTION MATERIAL C31.STEEL C] 4.FIBERGLASS 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b. <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: 1 certify that t ST system is compatible with the hazardous substance stored and that the information provided herein is true, <br /> accurate,and i 11 lance with legal requirements. <br /> APPLICANT SIGNATURE DATE 1 tnt'T �� 470. <br /> APPLICANT NAME(print) 471. APPLICANT TITLE A r 472. <br /> UPCF UST-13 Rev.(12/2007)-1/2 www.unidocs.org ,V <br />