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i i UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK f OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. For a UST closure or rentoral,complete only this section and Sections I,II,III.IV,and LY belott) 430. 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430. DATE EXISTING UST DISCOVERED:2-7 OCA 7 11 43ft I. FACILITY INFORMATION FACILITY ID#(Agency Use Onl)+) _ _ 1. BUSINESS NAME(Sante as Facility Nonte or DBA-Doing Business As) 3. f:7v eA_ LC-Seo F (LI BUSINESS SITE ADDRESS 103. CITY 104. H. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433• TANK CONFIGURATION:THIS TANK IS 434. �[ `t ` I.A STAND-ALONE TANK Complete once page for ewh VAl" t! 2.ONE IN A COMPARTMENTED UNIT companment in the wit. 3 DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 43Z -5,000 fL III. TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUEIdNG 439. ❑ 3.CHEMICAL.PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)) ❑ 6.OTHER GENERATOR FUEL 95.UNKNOWN ❑ 99.OTHER(S P fy1ed d39a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.NtIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440. ❑ 3.DIESEL. ❑5.JET FUEL ❑6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ta 9.OTHER PETROLEUM(Specify): + GH I91 c F L 440a NON-PETROLEUM:❑ 7.USED OIL El 10.ETHANOL 19 11.OTHER NON-PETROLEUMI.S eci.y): W [„ 4406. IV. TANK CONSTRUCTION TYPE OF TANK 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT ❑ I.STEEL ❑3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444- El 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN [K 99.OTHER(Specify): (QNGft13TIM 444a SECONDARY CONTAINMENT ❑ 1.STEEL [13.FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER ❑ 1.JACKETED 445 j 90.NONE _C195.UNKNOWN [199.OTHER(Specify): 445a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS RE UIRENIENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT j V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ❑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 ❑ 8.FLEXIBLE ❑ I0.RIGID PLASTIC 464. ❑ 90.NONE ❑95.UNKNOWN ❑ 99.OTHER(Specify): 464& SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. ❑90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Spec' ): 464c. PIPINGfrURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑2.DOUBLE WALL ❑90.NONE 464d VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT r�T 1.STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑90.NONE ❑ 99.OTHER S eci 464e. �` (P fY) 464el. VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC '®90.NONE ❑ 99.OTHER(Specify): 4464Wf1 VR PRIMARY CONTAINMENT ® L STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑90.NONE ❑ 99.OTHERS eci { (P fY)� 467418. VR SECONDARY CONTAINMENT ❑ L STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC 03 90.NONE ❑ 99.OTHER(Specif3') 464E 464111. VENT PIPING TRANSITION SUMP TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL M 90.NONE 464i' RISER PRIMARY CONTAINMENT 1.STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC ❑90.NONE ❑ 99.OTHER(Specify): 464-{ RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC R 90.NONE ❑ 99.OTHER(Specify): 4464 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATEMOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a c. VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE N 1.SINGLE WALL ❑2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑90.NONE 469a CONSTRUCTION MATERIAL ❑ h STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC 19 99.OTHER(Specify) (p W rE 469b' 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑2.SACRIFICIAL ANODES ❑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 an(4n f llcompliance wWLIggal r uirements. APPLICANT SIGNATURE ` DATE ;AN Z 470• APPLICANT NAME(print) l4� 471. APPLICANT TITLE472. MA UPCF UST-B Rev.(122007)-112 r♦ww.unidocs.org