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UPCF UST -B - 1/2 _"31 Rev. (12/2007) UNIFIED PROGRAM CONSOLIDATED FORM / Z 0 q( p 1 UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (One form per UST) T E 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 ❑ 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) 1 _ _ A 61 A BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) r�Rsr EVE9��99N a K� P � C' s �� 3 BUSINESS SITE ADDRESS 103 /6/Z, W, 4nmwt�, C,ti,e CITY 3 3 -To 104 1 �N C4 Q( a II. TANK DESCRIPTION TANK ID #A _ 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 - y� l� ,& . A STAND-ALONE TANK JE V S c V [12. ONE IN A COMPARTMENTED UNIT. Complete one page for each compartnent in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 III. TANK USE AND CONTENTS' TANK USE ® la. MOTOR VEHICLE FUELING ❑ lb. MARINA FUELING ❑ lc. 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.OTHERS OTHER(Specify): 439a CONTENTS PETROLEUM: la. REGULAR UNLEADED ❑ Ic. MIDGRADE UNLEADED - lb. PREMIUM UNLEADED 440 3. DIESEL ❑ 5. JET FUEL LJ 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 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL 2. DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT L STEEL Lr 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99.OTHER(S ): 444a SECONDARY CONTAINMENT ❑ 1. STEEL 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445 ❑ 90. NONE 95. UNKNOWN ❑ 99. OTHER (Specify): 445a OVERFILL PREVENTION ❑ 1. AUDIBLE & VISUAL ALARMS 0 2. BALL FLOAT 3. FILL TUBE SHUT-OFF VALVE 452. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL REVENTION EQUIPMENT V. PRODUCT/ WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1. SINGLE-WALLED2. DOUBLE -WALLED ❑ 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 R4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1. STEEL P�4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 4646 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464c PIPINGiTURBINE CONTAINMENT SUMP TYPE Er 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE 464d VL VENT, VAPOR RECOVERY (VR),AND RISER/ FILL. PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1. STEEL 5(4. FIBERGLASS 0 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464e VENT SECONDARY CONTAINMENT ❑ 1. STEEL ❑' 4. FIBERGLASS ❑ 10. RIGID PLASTIC 90. NONE ❑ 99. OTHER (Specify) 464el 464f VR PRIMARY CONTAINMENT 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464fl 4648 VR SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC 90. NONE ❑ 99. OTHER (Specify) 464RI 464h VENT PIPING TRANSITION SUMP TYPE ❑ I. SINGLE WALL ❑ 2. DOUBLE WALL 90. NONE 464h1 464i. RISER PRIMARY CONTAINMENT tL 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464j RISER SECONDARY CONTAINMENT ❑ L STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC 90. NONE 0 99. OTHER (Specify) 464'1 464k FILL COMPONENTS INSTALLED" 1. SPILL BUCKET 3. STRIKER PLATE/BOTTOM PROTECTOR ❑ 4. CONTAINMENT SUMP 464kl 45la-c VII. UNDER D JISPENSER CONTAINMENT.(UDC). CONSTRUCTION TYPE 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 469a CONSTRUCTION MATERIAL 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 469b -c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 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, and in full coraiiiiance with legal re uire eats. APPLICANT SIGNATURE DATE n 1�t� -0b 470• APPLICANT NAME (print) 471' MR(iPPr APPLICANT TITLE a 47-• UPCF UST -B - 1/2 _"31 Rev. (12/2007)