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a 0 UNIFIED PROGRAM CONSOLIDATED FORM 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 [31.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 I DATE EXISTING UST DISCOVERED: 430b i. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 0 i V ! � Ll I 1 BUSINESS N (Same as FACI TY NAME or DBA-Doing Business As) 3 I &--,Qs +, BUSINESS SITE PDDREIS 103 1 CTTy j 104 H.TANK DESCRIPTION TANK ID# ,!' 432 TANK MANUFACTURER 433 TA ONFIGURATION:THIS TANK IS 434 r� o STAND-ALONE TANK / I Lf 9 05 -) C o ❑2.ONE IN A COMPARTMENTED UNIT. {{{ Comelete one page for each compartinent in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 kfl.TANK USE AND CONTENTS' 1 TANK USE IRla.MOTOR VEHICLE FUELING ❑ Ib.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.OTHER(Specify): 439a CONTENTS PETROLEUM: 9 la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM ($ 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b IV. ,TANKCONSTRUC.TION . TYPE OF TANK ❑ 1.SINGLE WALL DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT IF 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL 3. ING ❑ 95.UNKNOWN El99.OTHER (specify): 444a SECONDARY CONTAINMENT 1.STEEL FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S445a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS . ALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT!WASTE PIPING CONSTRUCTION , PIPING CONSTRUCTION ❑ SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE RESSURE 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(aX3)] 458 PRIMARY CONTAINMENT 1.STEEL ❑4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑X.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL Off 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 5.UNKNOWN ❑ 29.OTHER(Specify): 464c PIPINGITURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL LJ 2.DOUBLE WALL ❑ 90.NONE 46aa VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL.PIPE PIPING CONSTRUCTION . VENT PRIMARY CONTAINMENT 0 1.STEEL 42r 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 464fl VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464d VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ W.NONE ❑ 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE W- DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT 1.STEEL t.FIBERGLASS U' 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464k 4641 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATEBOTTOM PROTECTOR 4.CONTAINMENT SUMP 45la-c VII.UNDERDISPENSER CONTAINMENT.(UDC). CONSTRUCTION TYPE Erl.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469ba VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION Sff?.SACRIFICIAL ANODE(S) [14.IMPRESSED CURRENT In 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 complissKe with legal requirements. APPLICANT SIGNA DATE 'z_1 j) ` 470. APPLICANT NAME Tint) 471. APPLICANT TITLE an. UPCF UST-B-1/2 Rev.(12/2007)