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UNIFIED PROGRAM CONSOLIDATED ffRM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,III,IV,and DC below) 430 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 0 7.UST PERMANENT CLOSURE ON SITE 0 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 BUSINESS SITE ADDRESS 103 CITY 104 H.TANK DESCRIPTION , TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 Sl(CIS;� 1.A STAND-ALONE TANK O ❑2.ONE IN A COMPARTMENTED UNIT. ConVIete one PaP for each cmParunent in the writ. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 CD c) - III.TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Ic.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑4.HAZARDOUS WASTE(I d Iles Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC¢25281.5())] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 919.OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS 11 ❑ 8.PETROLEUM BLEND FUEL J9 9.OTHER PETROLEUM (Specify): pip IDr p t 44N NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 11.OTHER NON-PETROLEUMS 440b 1V.`TANK:CONSTRUCTION TYPE OF TANK A.I.SINGLEWALL Q 2.DOUBLE WALL 95.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL 0 3.FIBERGLASS ❑ 6.INFERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 1190.NONE ❑ 95.UNKNOWN .OTHER(S ): ,.,ct..i-�V u� 445a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL 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 1:12.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR$2636(a)(3) 458 PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS 11 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL ❑4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b 90.NONE ❑ 95.UNKNOWN A 99.OTHER(Specify): Cv ,c�-s � c,/ 464c PIPING/TURBINE CONTAINMENT S:,,.P TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC If 90.NONE 0 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT L STEEL n 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464f 464f1 VR PRIMARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS El 10.RIGIDPLASTIC 90.NONE 99.OTHER(Specify) 4648 4640 VR SECONDARY CONTAINMENT L STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE 0 1.SINGLE WALL C3 2.DOUBLE WALL 90.NONE 464i RISER PRIMARY CONTAINMENT L STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT L STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464k FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR 46441 4.CONTAINMENT SUMP 4514•) VII.UNDER DISPENSERCONTAINMENT.(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 099.0 R(S ify) 469b•e VIII. 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 compliance with legal requimments. APPLICANT SIGNATURE DATE 470. APPLICANT NAME(print) 471. APPLICANT TITLE 472. UPCF UST-B-I/2 Rev.(12/2007)