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AML Now UNIFIED PRQQP=C==DLIDATED FORM GE TANK /6 /2 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,I1,III,IV,and IX below) 430 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE El 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 BUSINESS NAME(.}Same as FACJ(LITY NAME or DBA-Doing Business As) 3 BUSINESS SITE ADDRESS 103 CITY 104 II.TANK DESCRIPTION TANK 11)# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 /^� 1.A STAND-ALONE TANK 2.ONE IN A COMPARTMENTED UNIT. Complete one page for each cmyartrnm in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 /C0 c> III.TANK USE AND CONTENTS TANK USE r I la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE N 4.HAZARDOUS WASTE(Mud=Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[FISC§252845(c)] IJ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL `.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM: 7.USED OIL - 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): `fib IV. TANK CONSTRUCTION TYPE OF TANK 1.SINGLE WALL N 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT J8 I.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT Q 1.STEEL [13.FIBERGLASS r l 6.EXTERIOR MEMB "'^`^"^ ^ " "^ 445 ❑ 90.NONE ❑ 95.UNKNOWN !".OTHER(Specify): 445a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS ❑ 2.bAj L FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452• 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 1.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(ax3)] 458 PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS of 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b 90.NONE ❑ 95.UNKNOWN 99.OTHER(Specify): L", '_�-(- 464c PIPING/TURBINE CONTAINMENT'--...?TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 0 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 464f1 VR PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4648 464el 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 Lj 1.STEEL U 4.FIBERGLASS Lj 10.RIGID PLASTIC 90.NONE Ll 99.OTHER(Specify) 464] 464'l RISER SECONDARY CONTAINMENT 0 L STEEL 4.FIBERGLASS El 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464k 464kl FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 451a- VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS JM 90.NONE 469a CONSTRUCTION MATERIAL ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT JM 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 compliance with legal requirements. APPLICANT SIGNATURE DATE 470. APPLICANT NAME(print) 471. APPLICANT TITLE 471-. UPCF UST-13-1/2 Rev.(12/2007)