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4WIFIED PROGRAM CONSOLIDATED FCW <br />UNDERGROUND STORAGE TANK <br />OPERATING PERMIT APPLICATION - TANK INFORMATION (One form per UST) <br />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 <br />X 1. NEW PERMIT ❑ 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION <br />❑ 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL <br />DATE UST PERMANENTLY CLOSED: 431a DATE EXISTING UST DISCOVERED: 430b <br />TANK USE x la. MOTOR VEHICLE FUELING ❑ lb. MARINA FUELING ❑ Ic. AVIATION FUELING <br />439 <br />❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 5. EMERGENCY GENERATOR FUEL [HSC §25281.5(c)] <br />❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): <br />439a <br />CONTENTS PETROLEUM: ❑ la. REGULAR UNLEADED ❑ lc. MIDGRADE UNLEADED X 1b. PREMIUM UNLEADED <br />440 <br />❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS <br />❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (Specify): <br />440a <br />NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL <br />❑ 11. OTHER NON -PETROLEUM (Specify): <br />440b <br />I. T1fiK CCN$TtUC _N. <br />TYPE OF TANK ❑ 1. SINGLE WALL x 2. DOUBLE WALL ❑ 95. UNKNOWN <br />443 <br />PRIMARY CONTAINMENT ❑ 1. STEEL X 3. FIBERGLASS ❑ 6. INTERNAL BLADDER <br />444 <br />❑ 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): <br />444a <br />SECONDARY CONTAINMENT ❑ 1. STEEL X 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED <br />445 <br />❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): <br />445a <br />OVERFILL PREVENTION ❑ 1. AUDIBLE & VISUAL ALARMS ❑ 2. BALL FLOAT x 3. FILL TUBE SHUT-OFF VALVE <br />452. <br />❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br />.> Y., PRODUCT /WASTE`Y'ING.CONTRUCTION <br />PIPING CONSTRUCTION ❑ 1. SINGLE -WALLED x 2. DOUBLE -WALLED [199. OTHER <br />460 <br />SYSTEM TYPE x L PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR §2636(a)(3)] <br />458 <br />PRIMARY CONTAINMENT ❑ L STEEL X 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC <br />464 <br />❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER(Specify): <br />464a <br />SECONDARY CONTAINMENT ❑ 1. STEEL x 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC <br />464b <br />❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): <br />464c <br />PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE <br />464d <br />.;' 1TyAPt R REC,OVERX ( j „RI; ER:1 CtvviFE PIPING,C NSTRUCTION = <br />VENT PRIMARY CONTAINMENT ❑ L STEEL x 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) <br />464e <br />464el <br />VENT SECONDARY CONTAINMENT ❑ 1. STEEL x 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) <br />464f <br />464£1 <br />VR PRIMARY CONTAINMENT ❑ I. STEEL X 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) <br />4648 <br />464gl <br />VR SECONDARY CONTAINMENT ❑ L STEEL X 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) <br />464h <br />464h1 <br />VENT PIPING TRANSITION SUMP TYPE ❑ 1. SINGLE WALL x 2. DOUBLE WALL ❑ 90. NONE <br />4641. <br />RISER PRIMARY CONTAINMENT x L STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) <br />464j <br />464j I <br />RISER SECONDARY CONTAINMENT ❑ 1. STEEL x 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) <br />464k <br />464k1 <br />FILL COMPONENTS INSTALLED x 1. SPILL BUCKET x 3. STRIKER PLATE/BOTTOM PROTECTOR x 4. CONTAINMENT SUMP <br />45l a -c <br />UPCF UST -B - 1/1 Rev. (12/2007) <br />