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UNIFWIZ AACR* .CONSOLIDATED RM c_��R D 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,11,III,IV,and IX below) 430 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE El 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 II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 .. _ 21. R 1.A STAND-ALONE TANK (ti C) ✓( �j s�C) [12.ONE IN A COMPARTMENTED UNIT. ConnAde one page for each compounm in the writ. DATE UST SYSTEM INSTALLED 435 TANK CAPer'TT v IN rALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 2Sc. III.TANK USE AND CONTENTS' TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc.AVIATION FUELING 439 B 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§2528I.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL J9 9.OTHER PETROLEUM (Specify): 11 4;__ QD 440. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 11.OTHER NON-PETROLEUM(Specify): "Ob IV. _TANK CONSTRUCTION TYPE OF TANK AN 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT JR 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL 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 ❑ 90.NONE ❑ 95.UNKNOWN .OTHER(Specify) .- -�V 4( 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 CONSTRUCTION1.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION 0 4.SAFE SUCTION(23 CCR§2636(a)(3) 458 PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS IR &FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT r l L STEEL ❑ 4.FIBERGLASS 8.FLEXIBLE 0 10.RIGID PLASTIC 464b 90.NONE ❑ 95.UNKNOWN 2t99.OTHER(Specify): ".4.4 464c PIPINGITURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 10 90.NONE 464d VI.VENT,VAPOR RECOVERY")AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL El 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT L STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT L STEEL U 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464g 46421 VR SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE EJ 99.OTHER(Specify) 46411 464hl VENT PIPING TRANSITION SUMP TYPE 0 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 464i RISER PRIMARY CONTAINMENT U L STEEL Ll 4.FIBERGLASS Lj 10.RIGIDPLASTIC 90.NONE M 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT 1.STEEL El 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE EJ 99.OTHER(Specify) 464k 464kl FILL COMPONENTS INSTALLED 0 1.SPILL BUCKET 0 3.STRIKER PLATEBOTTOM PROTECTOR 4.CONTAINMENT SUMP 451a VII.UNDER DISPENSER CONTAINMENT.(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS $j 90.NONE 469. CONSTRUCTION MATERIAL ❑ L STEEL 0 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 99.OTHER(Specify) 469b•c VIII.. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 01 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 472. UPCF UST-B-1/2 Rev.(12/2007)