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Adk <br /> 11t <br /> OFIED PROGRAM CONSOLIDATED FO QI to <br /> UNDERGROUND STORAGE TANKOPERATING PERMIT APPLICATION-TANK INFORMATION (One for <br /> TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,II,111,IV,and IX below) 430. <br /> ❑ 1.NEW PERMIT 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430x. I DATE EXISTING UST DISCOVERED: 430b. <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name1 /orr DBA-Doing Business As) 3. <br /> -TRACx-/ 6j0 �V 1W CZA) 15� <br /> BU -75_ I �� 103 CITY toes. <br /> II. TANK DESCRIPTION <br /> TANK ID# 432. TANK MANUFACTURER 433. TA>K CONFIGURATION:THIS TANK IS 434. <br /> �� 1.A STAND-ALONE TANK Complete one page for each <br /> 7-A0A0 /qQ 7 2.ONE IN A COMPARTMENTED UNIT compartment in the unit. <br /> DATE UST SY TE INSTALLED 435. TANK C PAC GALLONS 436. NUMBER OF COMP RTMENTS IN THE UNIT 43z <br /> L <br /> III. TANK USE AND CONTENTS <br /> TANK USE ff la.MOTOR VEHICLE FUELING ❑ ]b.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 - 0 95.UNKNOWN ❑ 99.OTHER(Specify): 439a. <br /> ...... __ ....._............._.... ........... . __. ... .... _ .._.... .. .. ....40.. <br /> .. <br /> CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ 1b.PREMIUM UNLEADED 4 <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> 8 LEU <br /> PETROM BLEND FUEL 9 OTHER PETROLEUM(Specify): {^� 440a. <br /> W, <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUM(Specify): 4406. <br /> . TANK CONSTRUCTION <br /> TYPE OF TANK 0 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443. <br /> ....................._....................._........... <br /> _.............................................................................................._...._..............._....._................_....__....._...-.._....................._.__.................._........._........._............................._....................._........................................................................._........._...-........._........ <br /> PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. <br /> 7 STEEL+INTERNAL INING 95.UNKNOWN 0-99.OTHER(Specify): 444x. <br /> ❑ ................ 0....- -- - <br /> ---........__...._...... <br /> SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS Q 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a. <br /> -......_.._....................................._........................._................................................._........_.........._.........................._........................ ------....---......_.............._...__............_..._................................_......... _.................................... <br /> OVERFILL PREVENTION ❑ I.AUDIBLE&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 /> _.__..__........._...._._._..............._........._.......................... ...... . .................._........................._-....._........_....__............._.._.__................._............................._.._..._......_..._...._..........._....................................ass <br /> SYSTEM TYPE 1.PRESSURE O.__2.GRAVITY O.3.CONVENTIONAL SUCTION 0....4.:.SAFE SUCTION[23 CCR§2636(a)(3)]_...........__..._._........... <br /> ......_..._..........._..__........__'---._...................._....... .... ....._...__._ ............... ..... ... ..__ ._._. .... .. .................. _ 464 <br /> .. ......... <br /> PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC <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 OTHERS ci 464c. <br /> ...._....:.._._.__......._............._...._.._._.....__..._..._.........._........._........._..............._............_............._...........................�._�..._?_�....... <br /> .................................I................... <br /> PIPING/TU' CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL O 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): 46ael. <br /> ._.........._.......................__.......__..._...---._............._......_.............................................._..........................................._..............................._................_-._.........__..__.................._.._.........._..........._..__.._......_._...............................__.................._..........._............................_......................__... <br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46 ff <br /> .............................................................................................._................................-..._..................................._......._.._............................_..._.._._.................._....................._........................_....................---..............._.-..._............._...._....__._.._.._..._..._..._...._.._...._......_........-- <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464 1. <br /> _g_.. <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464hl. <br /> .................... ...................................._.._..-..._....._.......................__...................._.._............_.. --- ----............_....._..............-.............................._..............................................._........_......._....._._...................................._........_......._.....__....__..... _... <br /> VENT PIPING TRANSITION SUMP TYPE O 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464` <br /> ..................._..._...---._.._.._.._.._.._........-....._.........._..........._...............................................................................................---....._---------..............................- ._........... -.._._.._...............-...................._......................._.................................................................................-......................... <br /> ......_........_................4,_ <br /> 46 I. <br /> RISER PRIMARY CONTAINMENT ❑ ...STEEL ❑ ...FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464jL__. <br /> _.._........_.._..........._........_...................._....- - ...._.__.._..............._..--........._......_................................................._..............................................._..._._._.._......__............._.................................-....._......._.,._._... 464k.. <br /> RISER SECONDARY CONTAINMENT 1.STEEL ❑ 4.FIBER LASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464k1 <br /> ........................._...._..._......------............._.._................._......._....................._ ............................................._........_.............................._..__._...------....._..........._.....__..._....-._._...............__................... .._.._........._...__............................................................................._....._. ---.. <br /> FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c. <br /> . UNDER DISPENSER CONTAINMENT (UDC) <br /> CONSTRUCTION TYPE 1.SINGLE WALL 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a. <br /> _.........................................._............._........._._..........................__......................_.........._..-...._...._._......._........_......_.__...................__........_................................................._.........._.................._..........._..__.......__......_.......... _............._.__.-.......__........._............._....._...... <br /> ....... <br /> -........... <br /> _......... <br /> ......4_.._._...... <br /> CONSTRUCTION MATERIAL 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696 <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION O 2.SACRIFICIAL ANODE(S) O 4.IMPRESSED CURRENT O 6.ISOLATION 448. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify th t his ST system is compatible with the hazardous substance stored and that the information provided herein is true, <br /> accurate,a in ll Sompjiance w' al requirements. <br /> APPLICANT SIGNATURE DATE 1 /4 <br /> 470. <br /> APPLICANT NAME(print) - 471. APPLICANTTIfLE 472. <br /> kj <br /> UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org <br />