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t 0 9� 'lZ .,4 AL ! �N7 UNIFIED PROGRAM CONSOLIDATED FORM U !! UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION 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 ❑ 1. NEW PERMIT 3. RENEWAL PERMIT ❑ 5. CHANGE O 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE 0 8. UST REMOf DATE UST PERMANENTLY CLOSED: 430a I DATE EXISTING UST DISCOVERED: J' L FACILITY INFORMATION FACILITY ID # (Agency Use Only) _ _ / BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) i r CAS'CA M XGA BUSINESS SITE ADDRESS 103 II. TANK DESCRIPTION Ii-Egm TANK ID # --'I-:A� � G. J l C) / 432 411 10 TANK MANUFACTURER 433 r TANK CONFIGURATION: THIS TANK IS �,j. A STAND-ALONE TANK [12. ONE IN A COMPARTMENTED UNIT. Cpmpletc one page for each con4mrwod in the unit 434 DATE UST SYSTEM INSTALLED 435 ck TANK CAEACI tIN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 III. `BANK USE AND CONTENTS TANK USEL la. MOTOR VEHICLE FUELING ❑ Ib. MARINA FUELING ❑ lc. AVIATION FUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (hadudes Used 00) ❑ S. EMERGENCY GENERATOR FUEL [HSC I25281.5(e)] ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ I a. REGULAR UNLEADED ❑ lc. MIDGRADE UNLEADED X1 b. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM S 440 440a NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL 1 L OTHER NON -PETROLEUMS 440b IV. TANKCONSTRUCTIQN TYPE OF TANK ❑ 1. SINGLE WALL 2. DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT 13 1. STEEL JJL 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 7. STEEL+ INTERNAL LINING ❑ 95. UNKNOWN ❑ ".OTHER(S 444 444a SECONDARY CONTAINMENT 131. STEEL 3. FIBERGLASS [36. EXTERIOR MEMBRANE LINER ❑ 7. IACKETED SM ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (S ): 445 445a OVERFILL PREVENTION I.AUDIBLE & VISUAL ALARMS 2. BALL FLOAT . FILL TUBE SHUT-OFF VALVE 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT 452. V.PRODUCT /WASTE PIIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1. SINGLE -WALLED 2. DOUBLE -WALLED---- 13 ". OTHER 460 SYSTEM TYPE PRESSURE ❑ 2. GRAVITY Q 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION (23 CCR §2636(#3)1 458 PRIMARY CONTAINMENT 13 L STEEL 4. FIBERGLASS 8. FLEXIBLE ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER(Spec*): 464 464a SECONDARY CONTAINMENT L STEEL 4. FIBERGLASS ❑ 8. FLEXIBLE 10. RIGID PLASTIC ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 4646 464c PIPING/TURBINE CONTAINMENT SUMP TYPE M. SINGLE WALL 2. DOUBLE WALL Q 90. NONE 4644 VI. VENT, VAPOR RECOVERY (YR)AND RISER I DILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENTU 1. STEEL JR 4. FIBERGLASS U 10- RIGID PLASTIC U 90. NONE 0 ".OTHER (Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ 1. STEEL JK 4. FIBERGLASS 0 10. RIGID PLASTIC JR 90. NONE 99.OTHER (Specify) 464f 464fl VR PRIMARY CONTAINMENT At1. STEEL JZ 4. FIBERGLASS 13 10. RIGID PLASTIC 90. NONE 0 99.0THER (Specify) 4648 1 VR SECONDARY CONTAINMENT 0 1. STEEL 1& 4. FIBERGLASS ❑ 10. RIGID PLASTIC ' 90. NONE 99. OTHER (Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE Q 1. SINGLE WALL E&Z DOUBLE WALL IN 90. NONE 464L RISER PRIMARY CONTAINMENT 1. STEEL 4. FIBERGLASS U 10. RIGID PLASTIC U 90. NONE 0 99. OTHER (Specify) 464i 464'1 RISER SECONDARY CONTAINMENT 0 1. STEEL IK4. FIBERGLASS 10. RIGID PLASTIC 0 90. NONE 99.OTHER (Specify) 464k 4641 FILL COMPONENTS INSTALLED WJ. SPILL BUCKET 3. STRIKER PLATEIBOTTOM PROTECTOR 0 4. CONTAINMENT SUMP 451ac VII. UNDER DISPENSER CONTAENMCNT.(UDC), CONSTRUCTION TYPE 1. SINGLE WALL 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 469a CONSTRUCTION MATERIAL 1LI. STEEL Q 4. FIBERGLASS 0 10. RIGID PLASTIC ❑ ".OTHER (Spec*) ) 469bc VIII. CORROSION PROTEC'ITON STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT6. ISOLATION 448• UL APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substanice stored and that the information provided herein is true, accurate, and is full complia!EejMth legal requirements. APPLICANT SIGNATURE ,/yl- DATE Z /vQ 4.0. APPLICANT NAME (print) '7 471' VY`.. Yeo ►� i-� � APPLICANT TITLE L 4n' UPCF UST -B -1/2 2/2007)