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FIED PROGRAM CONSOLIDATED FCFW 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 X 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: 431a DATE EXISTING UST DISCOVERED: 430b TANK USE x la. MOTOR VEHICLE FUELING ❑ lb. MARINA FUELING ❑ 1c. AVIATION FUELING 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 (Specify): 439a CONTENTS PETROLEUM: X la. REGULAR UNLEADED ❑ lc. MIDGRADE UNLEADED ❑ lb. PREMIUM UNLEADED 440 ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (Specify): 440a NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ❑ 11. OTHER NON -PETROLEUM (Specify): 440b TYPE OF TANK ❑ 1. SINGLE WALL x 2. DOUBLE WALL ❑ 95. UNKNOWN ""' PRIMARY CONTAINMENT ❑ 1. STEEL X 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 ❑ 7 STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1. STEEL X 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 445a OVERFILL PREVENTION ❑ 1. AUDIBLE & VISUAL ALARMS ❑ 2. BALL FLOAT x 3. FILL TUBE SHUT-OFF VALVE 452. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT PIPING CONSTRUCTION ❑ I. SINGLE -WALLED x 2. DOUBLE -WALLED ❑ 99. OTHER L_I yu. INVINZ ❑ 90. NONE ❑ 99. OTHER (Specify) 460 SYSTEM TYPE x 1. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR §2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ 1. STEEL X 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC aha ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER(Specify): ❑ 1. STEEL x 4. FIBERGLASS ❑ 10. RIGID PLASTIC 464a SECONDARY CONTAINMENT ❑ L STEEL x 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464b ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE 464d V `SENT, VAPOR;RECOirEIZY (YR} AD- RSC ER'�+'II,L PIPE PIPING Cf3NSTRUC CION VENT PRIMARY CONTAINMENT ❑ 1. STEEL x 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ L STEEL x 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464f 46417] VR PRIMARY CONTAINMENT ❑ L STEEL X 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 4648 464gl VR SECONDARY CONTAINMENT ❑ L STEEL X 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464h VENIPIPINU IRANSf11UN SUMP I YPE; RISER PRIMARY CONTAINMENT 1J 1. SINULC WALL X L. UDUtlLC WALL x 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC L_I yu. INVINZ ❑ 90. NONE ❑ 99. OTHER (Specify) 464j 464j l RISER SECONDARY CONTAINMENT ❑ I. STEEL x 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464k 4641 FILL COMPONENTS INSTALLED x 1. SPILL BUCKET x 3. STRIKER PLATE/BOTTOM PROTECTOR x 4. CONTAINMENT SUMP 451 a -c ❑ 3. NO DISPENSERS ❑ 90. NONE 469a CONSTRUCTION TYPE X 1. SINGLE WALL ❑ 2. DOUBLE WALL CONSTRUCTION MATERIAL ❑ 1. STEEL x 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 469b -c STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION 448, 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) Dulcinea Covan 471. APPLICANT TITLE Compliance Manager 471 UPCF UST -B -1/1 Rev. (12/2007)