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1 Ada NIFIED PROGRAM CONSOLIDATED FOW. . UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATI (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 ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 0 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 19 1 _ 1 Q4 � E - 1510, 10 :1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 Dclry)e'ron `� BUSINESS SITE ADDRE S 103 CITY r 104 e So�KvYI A a 1c� II.TANK DESCRIPTION TANK ID# (' 32 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 I.A STAND-ALONE TANK Mu c r n 'A'� -I 2.ONE IN A COMPARTMENTED UNIT. �/V G 1 Co lete one for each co t in the writ. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALL014S 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 III.TANK USE AND CONTENTS TANK USE ❑ la.MOT VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439 ('',v�o �b ❑ 3.CHEMI AL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) 5.EMERGENCY GENERATOR FUEL[HSC¢25281.5(c)] n��n�fff 6.OTHER ENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): a39a 1�v�• CONTENTS PETROLE ❑ la REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ ]b.PREMIUM UNLEADED 440 3.DIESEL [15.JET FUEL ❑ 6.AVIATION GAS I 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 44ob NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM S IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL K 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 4a4 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER S ): 444a SECONDARY CONTAINMENT ❑ 1.STEEL W.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE 95.UNKNOWN ❑99.OTHER S i445a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT XL 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑I.SINGLE-WALLED .DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPEPRESSURE [12.GRAVITY [13.CONVENTIONAL SUCTION [14.SAFE SUCTION[23 CCR 62636(ax3)] 458 PRIMARY CONTAINMENT ❑ 1.1.STEEL4.FIBERGLASS [18.FLEXIBLE El 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ^I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT 1.STEEL [j4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464f 464£1 VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464g 464 1 VR SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99 OTHER(Specify) 464i 464'1 RISER SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATF/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 451ac VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 0 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b� VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION cam;414 448, IX. APPLICANT SIGNATURE _ 4tin rccd FIASfic CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the informadd, reYided herein is true,accurate, and i ll compliance with legal reuirements. 470. APPLICANT SIGNATU DATE � 01/20 3 1If an. 472. APPLICANT NAME(print) APPLICANT J�ttTLE ao �?WieDicec.}vr V111' UPCF UST-B-1/2 Rev.(12/2007)