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UNIFIED PROGRAM CONSOLIDATED FORM 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 IX below) 430 ❑ I.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 L FACILITY INFORMATION FACILITY ID#(Agency Use Only) I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 e ,.__ rte'- • l %f,c', _ BUSINESS SITE ADDRESS . 103 CITY 104 II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 f 1 5/ Q 1.A STAND-ALONE TANK l 6 S! ❑2.ONE IN A COMPARTMENTED UNIT. COMPIde one pap for each cwwazwmd in the twit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 III.TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC¢25281.5(e)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL J9 9.OTHER PETROLEUMS M o�e _ t�t' / 440. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 11.OTHER NON-PETROLEUM(Specify): 440b IV.'-TANK CONSTRUCTION TYPE OF TANK JS 1.SINGLE WALL 0 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT JS 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S ): 444& SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS--- ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN .OTHER(S ): .,�,-a-�v u I 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 ❑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 Q1 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT rl 1.STEEL CI 4.FIBERGLASS 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4641 W.NONE ❑ 95.UNKNOWN 99.OTHER(Specify): Q.N(& 464c CONTAINMENT SU PIPING/TURBINE URSINE MP TYPE ❑ 1.SINGLE WALL Ll 2.DOUBLE WALL Jj6 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS C1 10.RIGIDPLASTIC 90.NONE 0 99.OTHER(Specify) 4641' 464Fl VR PRIMARY CONTAINMENT El I.STEEL U 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 4648 464 1 VR SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE El 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE Ej 1.SINGLE WALL ----C72.DOUBLE WALL 90.NONE 464i. RISER PRIMARY CONTAINMENT Lj L STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT 0 L STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464, 464k1 FILL COMPONENTS INSTALLED 0 1.SPILL BUCKET 0 3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT.(UDQ CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS 90.NONE 469& CONSTRUCTION MATERIAL ❑ 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b, 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 requirements. APPLICANT SIGNATURE DATE 470. APPLICANT NAME(print) 471' APPLICANT TITLE 4r• UPCF UST-B-1/2 Rev.(12/2007)