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r Ah UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR OPERATING PERMIT APPLICATION - TANK INFORMATION PRIMARY CONTAINMENT 0 1. STEEL (one form per UST) §2636(ax3)] ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 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 ❑ 99.OTHER(Specify): 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL SECONDARY CONTAINMENT ❑ 1. STEEL DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 430b L FACILITY INFORMATION ❑ 90. NONE FACILITY ID # (Agency Use Only) ❑ 99. OTHER (Specify): 464c 1 BUSINESS NAME (Same as FACILITY NAME or DBA -Doing BusinessAs) 3 qas Fuyzo VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL.PIPE.PIPING`-CONSTRUCTION BUSINESS SITE ADDRESS to3CITY VENT PRIMARY CONTAINMENT 0 1. STEEL 104 H. TANK DESCRIPTION 464e TANK ID # r� c 432 TANK MANUFACTURER 433 Te CONFIGURATION: THIS TANK IS "sf I. 434 - . A STAND-ALONE TANK T f Us 464el 464f Ct� 2.ONE IN A COMPARTMENTED UNIT . ❑ 4. FIBERGLASS ete one fbrcachewipmuneminthemit. DATE UST SYSTEM INSTALLED 435 TANK CAPAf'ITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 Try ❑ 4. FIBERGLASS III'TANK USE AND CONTENTS ` 464 I U. TANK USE la. MOTOR VEHICLE FUELING ❑ lb. MARINA FUELING ❑ lc. AVIATION FUELING 439 ❑ . 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: i la. REGULAR UNLEADED ❑ Ic. MIDGRADE UNLEADED lb. PREMIUM UNLEADED 440 ❑ 3. DIESEL ❑ 5. JET FUEL 9 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM S 440a NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ❑ 11. OTHER NON -PETROLEUMS 440b IV.`- AWCONSTRUCTION TYPE OF TANK ❑ I. SINGLE WALL 2. DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT 1. STEEL ❑ 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ I. STEEL 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 9 445 ❑ 90. NONE 95. UNKNOWN ❑ 99. OTHER (Specify): 445a OVERFILL PREVENTION 1. AUDIBLE & VISUAL ALARMS 2. BALL FLOAT IS, 3. FILL TUBE SHUT-OFF VALVE 452. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT_/, WASTE PIPING CONSTRUCTION PiPINC-0 rnN8TR1 V`TuIN r-11 crn.r_r a n>. r r nr. ....................... ... -- SYSTEM TYPEarl.PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR 460 458 PRIMARY CONTAINMENT 0 1. STEEL q 4. FIBERGLASS §2636(ax3)] ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1. STEEL 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGIDPLASTIC 464b ❑ 90. NONE 95. UNKNOWN ❑ 99. OTHER (Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE 464d VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL.PIPE.PIPING`-CONSTRUCTION DL APPLICANTSIGNATURE VENT PRIMARY CONTAINMENT 0 1. STEEL 4. FIBERGLASS ❑ 10. RIGID PLASTIC 0 90. NONE ❑ 99. OTHER (Specify) 464e VENT SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC X90. NONE ❑ 99. OTHER (Specify) 464el 464f VR PRIMARY CONTAINMENT 64 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99.OTHER (Specify) 464fl 464g VR SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC W 90. NONE ❑ 99. OTHER (Soecifv) 464 I U. 6 az- rn uuc i %,ViN 1 A1NMbN 1 [j4 I. STEEL U 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464j RISER SECONDARY CONTAINMENT 1. STEEL El 4. FIBERGLASS 10. RIGID PLASTIC 90. NONE 99. OTHER (Specify) 464.1 464k FILL COMPONENTS INSTALLED211.SPILLBUCKET 3. STRIKER PLATEBOTTOM PROTECTOR 4. CONTAINMENT SUMP 4641 451ac VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE00 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 469a CONSTRUCTION MATERIAL ghl.STEEL ❑ 4. FIBERGLASS ❑ 10.50113 PLASTIC ❑ 99. OTHER (Specify) 469bc VIII. CORROSION: PROTECTION - STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) [14. IMPRESSED CURRENT 6. ISOLATION f_ry- 448. DL APPLICANTSIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored that the information and provided herein Is and in fullAmmillance with [gal requirements. SCeurate, f.., APPLICANT SIGNATURE DATE470. 7-1 l -o APPLICANT NAME (print) 471' APPLICANT TITLE F 472• UPCF UST -B - 112 Rev.