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fOMFIED PROGRAM CONSOLIDATED FO �{ UNDERGROUND STORAGE TANK (Z // OPERATING PERMIT APPLICATION-TANK INFORMATION (( a form per UST) \0� TYPE;(O�F�ACMTION (Check one item only. For a UST closure or removal,complete only this section and Sections IIIIII,IY,and IXbelow) 430.1.NEERMIT 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL �1 DATE UST PERMANENTLY CLOSED: 430& DATE EXISTING UST DISCOVERED: 430b. L FACII.ITY INFORMATION FACILITY ID#(Agency Use Only) 1. B INESS NAME(Same as Facility Name or DBA-Doing Business As) 3. _ orL BUj SSS E ADDRESS 103• CITY 104. H. TANK DESCRIPTION TANK ID# 432. T jK MANUFA R 433. TANK CONFIGURATION:THIS TANK K 434. II-� © Ul`�,�y }/� ❑ 1.A STAND ALONE TANK C 'ptee one vage for each 0 O O V �A"��. 2.ONE IN A COMPARTMENTED UNIT co pmt m��1. DATE UST SYSTEM INSTALLED 435• TANK CAPACITY IN GALLONS 436- NUMBER OF COMPARTMENTS IN THE NIT 437. 61 Fe Guf?v III. TANK USE AND CONVENTS TANK USE---M la.MOTOR VEHICLE FUELING 13 16.MARINA FUELING ❑ Ic.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE p 4.HAZARDOUS WASTE(Iackwn used on) ❑ 5.EMERGENCY GENERATOR FU !;RM§25281.5(c)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN Q 99.OTHER(Specify): 439& CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED p lc.MIDGRADE UNLEADED 1b.PREMIUM UNLEADED 440. t ❑ 3.DIESEL ❑ 5.JET FUEL C.AVIATION GAS a ❑ 8.PETROLEUM BLEND FUEL p 9.OTHER PETROLEUM(Specify): 440L NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify). 410b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL'® 2.DOUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT --W I.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): ' 444a SECONDARY CONTAINMENT ❑ 1.STEEL --M 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED i 445. ❑ 90.NONE p 95.UNKNOWN ❑99.OTHER S . r 445& OVERFILL PREVENTION --M 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE452 i 4.TANK MEETS M&UIREMENTS FOR EXEMPTION FROM OVERFILL,PREVENTION EOUIPMENT i V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 99.OTHER 460. SYSTEM TYPE 1C$ 1.PRESSURE p 2.GRAVITY El3.CONVENTIONAL SUCTION [34.SAFE SUCTION(23 CCR I 16(.x3)) ass. PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC j 464. E] 90.NONE ❑ 95.uNKNowN ❑ 99.OTIIERR(Specify): 464& SECONDARY CONTAINMENT ❑ 1.STEEL �� 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. PIPING/TURBINE CONTAINMENT SUMP TYPE ---* i.SINGLE WALL p 2.DOUBLE WALL ❑ 90.NONE 4644 VI VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRU( CION VENT PRIMARY CONTAINMENT ❑ 1.STEEL�4.FIBERGLASS [310.RIGID PLASTIC E) 90.NONE ❑ 99,OTHER(Specify): I 46 el. VENT SECONDARY CONTAINMENT 131.STEEL -E]4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE p 99.OTHER(Specify): 464f1 VR PRIMARY CONTAINMENT ❑ 1.STEEL] 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4saaul11 VR SECONDARY CONTAINMENT ❑ I.STEEL--®4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4464h- 64b1. VENT PIPING TRANSITION SUMP TYPE -49 1.SINGLE WALL [12.DOUBLE WALL El90.NONE '' RISER PRIMARY CONTAINMENT --b 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4X I. RISER SECONDARY CONTAINMENT ❑ 1.STEEL---M 4.FIBERGLASS [310.RIGID PLASTIC ❑ 90.NONE 1399.OTHER(Specify): 464k a641c1. FILL COMPONENTS INSTALLED L SPILL BUCKET 3.STRQCER PLATEIBOTToM PROTECTOR 4.CONTAINMENT SU:: ,, 451". VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑2.DOUBLE WALL ❑ 3_NO DISPENSERS ❑ 90.N ,(E 469x. CONSTRUCTION MATERIAL '91I.STEEL ❑ 4.FIBERGLASS El10.RIGIDPLASTIC ❑ 99.OTHER(Specify) 46g�. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL A 4.DAMESSED CURRENT 6.ISOLATION 448, IX. APPLICANT SIGNATURE- CERTIFICATION:I certify that this UST system Is compatible with the hazardous sobstance stored and that the information provid: be ran is true, acewate,Anglin with lend requirements. APPLICANT SIGNATURE DATE 6 _- Q i 470. APPLICANT NAME(print) ,� -2 471. APPLICANT TITLE C9 r- s R 472 UPCF UST-B Rev.(11,12007)-1/2 www.as idocs org