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�I�I�Ip <br /> IED PROGRAM CONSOLIDATED FOAW <br /> UNDERGROUND STORAGE TANK l <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) l <br /> TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11,111,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: 430a. 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 /> 7"W 22>' 'Z--ZXU 1 C-f_ C tNT�t <br /> BUSINESS SITE ADDRESS 103. 1 CITY 104. <br /> �Z37 AJ TRA �T�Z,4 <br /> II. TANK DESCRIPTION <br /> TANK ID# 432. TANK MAN FACTURER 433. T,9NK CONFIGURATION:THIS TANK IS 434. <br /> T 4A A J� 1.A STAND-ALONE TANK Complete one page for each <br /> ❑ 2.ONE IN A COMPARTMENTED UNIT compartment in the unit. <br /> DATE UST SY TE INSTALLED a3s. TANK- PACITY IN GALLONS 436. NUMBER OF COMPA ENTS IN THE UNIT 437. <br /> l I <br /> III. TANK USE AND CONTENTS <br /> TANK USE ❑ la.MOTOR VEHICLE FUELING 4)4. <br /> b.MARINA FUELING ❑ lc.AVIATION FUELING 439. <br /> ❑ 3.CHEMICAL PRODUCT STORAGE 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 /> ............................................................................................-.............I............I... .........._..................._ ..................................... <br /> ............................................................................................... . ..440..... <br /> CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ ]b.PREMIUM UNLEADED <br /> ❑ 3.DIESEL5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL OTHER PETROLEUM(Specify). yid 440a. <br /> NON-PETROLEUM 7.USED OIL ❑ 10.ETHANOL <br /> _. . <br /> ����((//..` I ......... <br /> ❑ 11.OTHER NON-PETROLEUM(Specify): VA0 \ 4406. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443. <br /> _.................................... ........................................................................................................... ._.......................... ......_............................................ <br /> PRIMARY CONTAINMENT ❑ L STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444a. <br /> .................................._... ............................................... .................................. ..................._..........__._......................._................................I... <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. <br /> ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER(Specify): 445a. <br /> ....................................................................................-.............._........................................................._.........................._..._......................................................... <br /> ..... <br /> OVERFILL PREVENTION O 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. <br /> 04.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQ UIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 99.OTHER 460. <br /> ..............._...............................-.......................................I. ................................................................................_..............................._..........................._......._................................. <br /> SYSTEM TYPE ❑ 1.PRESSURE O 2.GRAVITY O 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 C199.OTHER(Specify): 464x. <br /> .............................................................................................................................._.................._.__................................................................................................................... <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. <br /> .......................... <br /> ............................. <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 1Z 90.NONE 464d. <br /> VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> 464e. <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464e1 <br /> ..---.........................._..................................._._............................. .....4...4....... <br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464£1. <br /> ..........................._. ...................................................................................__................................ ...4...4_....... <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464gg,_____ <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 ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE <br /> _..._....._..._..................................................................._.I................................................................................................................................................. _................................._............................... .......................................................................................................................................................................................................... <br /> ..4... - <br /> RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46 j <br /> ._...........................................................................................................................-........................._....._................_.._...................-............._....._.............................._......................................................-.............. <br /> ................................................_............ ................_........._._... 464k. <br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL C] 4.FIBERGLASS ❑ 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 <br /> VII. UNDER DISPENSER CONTAINMENT (UDC) <br /> CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 0 3.NO DISPENSERS 0.NONE 469a• <br /> _....... ..............._ ..........................._ ......... ..........._.. ......... <br /> .............................................._................................................ ..........._...... .. 4696. <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that s U system is compatible with the hazardous substance stored and that the information provided herein is true, <br /> accurate a n fu rn l ce with 1 irements. <br /> APPLICANT SIGNATURE DATE 470. <br /> APPLICANT NAME(print) ail' APPLICANT T T' arz' <br /> FAftJ <br /> UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org <br />