|
)
<br /> QED PROGRAM CONSOLIDATED F
<br /> UNDERGROUND STORAGE TANK
<br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (one form w usi)
<br /> TYPE OF ACTION (Check onr item only Fora closrar or removal,complete only this section acrd sections I,t f.,ur,•Y,and!X below) 430.
<br /> 0 I.NEW PERMIT RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION
<br /> 1:36.TEMPORARY UST CLOSURE © 7,UST PERMANENT CLOSURE ON SITE ❑ 8,UST REMOVAL
<br /> DATE U$T PERMANENTLY CLOSED: 430h- DATE EXISTING UST DISCOVERED; 43Db.
<br /> L FACILITY V ORMAITON
<br /> FACILITY ID#(Agemy Use Only) , ..
<br /> BUSINESS NAME(Sane as Facility Name or DBA-Doing Business A,c) 3,
<br /> P Am rn Lotpvc- T
<br /> BUSINESS SITE ADDRBS$ 103. CITY io4.
<br /> j CA
<br /> II: IBNR DESCRIPTION
<br /> TANK W# 432, TAIK MANUFACTURER 4.43, TANK CONFIGURATION;THIS TAMC iS
<br /> 434,
<br /> I S / �-r ❑ 1,A STAND•A1 ONE TANK Cnmpkte mea rAp R+reach
<br /> ONE IN A COMPARTMENTED UTA CMV."IMt in 0te uniL
<br /> DATE UST SYSTEM INSTALLED 435• TANK CAPACITY IN GALLONS 436• NUMBER OF COMPARTMENTS iN THE UNIT 437.
<br /> O 1 -zo n 0
<br /> M. TANK tTS�,A T) CONTE NTS
<br /> TANK USE is.MOTOR VEI#ICLE FUELING © lb.MARINA FUELING ❑ le.AVIATION FUELING 439•
<br /> 3.CH NUCAL.PRODUCT STORAGE ❑ 4.HA$ARDOUS WASTE(includes Uad Oit) 0 5.EMERGENCY GENERATOR FUEL(HSC$2528 4(e)l
<br /> __ ❑ 6.OTHER(inms TO FUEL_ _ ❑ 95,UNKNOW14_ _ ❑ E.-01r R SWNCENTS
<br /> PETROLEUM,
<br /> �,. 439a�C
<br /> P TROLEUM: 440,,REGARU1c.MIDORADC UNLEADED lb.PREMIUADED
<br /> C3 3. L
<br /> ❑ 5.JET FUST, Q 6.AVIATION GAS
<br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9,OTHER PETROLEITM SSpceity): 4400.
<br /> NON-PETROLEUM: 9,USED OIL .. ❑ 10 ETHANOL ---`
<br /> Q 11.OTHER NON.PnROLEUM S I : 440b.
<br /> -
<br /> Iy.•TANK CONS'X'l1rC-'T'ION
<br /> TYPE OF TANK 1.SINGLE WALL, 2.DOUBLE WALL ._A 95.UNKNOWN 443.
<br /> PRIMARY CONTAINMENT 1,STEEL Q 3.FIBERGLASS ❑ 6.INTERNAL BLADDER W. . _ 4Mi.
<br /> 7,EEELLffnRVAL LINING Q 95.UNKNOWN ❑ 99,OTII�R(SEccifV): 444"•
<br /> _ 445n,....... -
<br /> SECONDARY CONTAINMENT 1,STEEL F19Y;1LGLASS ❑ 6.EXTERIOR MEMBRANE LINER a 1S,
<br /> Q 7.JACKETED
<br /> 90.NONE t35.UNKNOWN 99.OTIMR(Specify
<br /> OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS Q 2,$A,LL FLOATFiLL TUBE SHUT OFT VALVE 452
<br /> ❑ 4,TANK MEETS RE EMENTS FOR EXEMPTION FROM O PREVENTION UTPM.FNI'
<br /> V. PlkODVCT,/WASTE.PIPING COT!' STRUC'I'I(3N
<br /> PmNQ CONSTRUCTION 0 L SiNGLE WALL DOUBLE WAiL T Q 99.OTHER 460.
<br /> SYSTEM TYPE __ _PRESSURE 2.GRAVITY_ (3 3.CONVENTIONAL SUCTION 0 4,SN!?.SUCI•iON[23 2636(0x3?]�75--
<br /> PRIMARY CONTAINMENT STEEL 4.FIBERGLASS ❑ B.FLEXi91,E ❑ 10.RIGID PLASTIC 4R4•
<br /> . ._ _3 90.NONE y 95,UNKNOWN ER
<br /> Q 99.OTH (,gpwify); 4640,
<br /> SECONDARY CONTAINMENT STEEL M- ERGLASS ❑ $,FLEXIBLE ❑ 10,RIGID PLA$TTC 464b.
<br /> _ _ _ _ 90,NONE 9$,UNKNOWN ❑ 99.OTHER(Specft 464e.
<br /> PIPT�NGlI URBINE CONTAINMENT SUMP TYPE 1,sTNGLE WLL_A - .DOUBLE WALL 90.NONE -� 464d.
<br /> Vi:: VENT;:V'APOR REC6VE X(YRS AND RISER/FII:L;p1pExtruxG rorisu TION. . ., .
<br /> VENT PRIMARY CONTAINMENT i,5tEEL 4.FiBERGT,ASS 0 10.RTGID PLASTIC ❑90,NONE _❑ 99.OTHER(Specify): 464e,
<br /> VENT SECONDARY CONTAINMENT 1.STEEL '171'4-FIBERGLAS$ C] I O..RIGID PLASTIC 9o.NONLT�C] 99,OTHER(Specify); °R4
<br /> _ aran
<br /> .
<br /> VR PRIMARY CONTAINMENT 1,STEEL `�4 FIBERGLASS ❑ l0.RIGID PLASTFC © 90.NONT; ❑ 99.OTHER e'
<br /> VR SECONDARY CONTAINMENT I.STEEL ❑ 4,FIBERGLASS_❑ 10.RIGID PLASTIC 90.NONE. .❑ 99,OTHER(Specify);
<br /> 46th I,
<br /> VENT PTPTNQ TRANSI ITON SUMP TYPE ❑ t.$TNGT,F WALL ❑ 2,WUBLB WALL 90.NONE 4 '
<br /> RISER PRIMARY CONTAINMENT
<br /> I.STEEL, p 4.FIBERGLASS ❑ I0.RIGTD PLASTIC ❑ 90.NONE ❑ 99.OTi-WR(Specify): 454"j.
<br /> RISER SECONDARY CONTAINMENT 40 1.STrEL 4.FIBERGLASS ❑ 10.RfGtD PLASTIC ❑ 90,NONE ❑ 99,OTImR(Spccify); 464].
<br /> 464k1.
<br /> FILL COMPONENTS INSTALLED 1.SPiLL 0UCKET 1 STRIKER PLATiJWnOM PROTECTOR ❑ 4,CONTAINMENT SUMP 4s1n c•
<br /> Vft- UNDER ATSPL+N9-8lt`CX'A, NT.(LT G
<br /> CONSTRUCTION TYPE 1.SiNGLE WALL �_w_ DOUBLE WALL Q 3.NO DISPENSERS ❑ 90,NONE` 46%.
<br /> CONSTRUCTION MATERIAL ~ i.STEEL 4.FIBERGLASS �[ 30,RIGID PLASTIC Q 99.OTHIsR(Spccify) - ~� 09
<br /> ' 9e
<br /> DTIII. ORl20SIOT'T 'RO'1
<br /> STEEL COMPONENT PROTFTION ❑ 2.SACRWICTAL A.NOD S 4.IMPRES$FD CURRENT 6. SOLATION 448,
<br /> YL. ,AcPPLIC 4n. SIGNA'T'URE
<br /> CER'11FICATION: i ccrGfy that this UST system Is compatible with the hazardous sabstmace stored and that the Information provhled hd*bLbt true,
<br /> amrate,and in fall eom liance with I I Mulremonts.
<br /> APPLICANT SIGNATURE DATE ' ,� 470.
<br /> APPLICANT NAME(print) 4�1. APPLICANT TITLE v472.
<br /> UPCIi UST-B Rev.(17,/2007)-1/2 www.unidemorg
<br />
|