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0 0 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. Fora ST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 430 [11.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: t 43oa DATE EXISTING UST DISCOVERED: 430b L 'FACILITY INFORMATION FACILITY ID#(Agency Use Only) F V 4 I BUSINE(&NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 r" r ( 6i,I"(IVCs 3" BUSINESS S-4� DIt5 { 4 , 103 CITY [ ,,� 104 II.TANK DESCRIPTION TANK 11)# / 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 (� ©� 01.A STAND-ALONE TANK ❑2.ONE IN A COMPARTMENTED UNIT. 1 Complete one page for each compartment in the urdt. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COA'-4 RTMENTS IN THE UNIT 437 qQ- III.TANK USE AND CONTENTS' TANK USE la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) 0 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] [16.OTHER GENER^'""R FUEL ❑ 95.UNKNOWN C] 99.OTHER(Specify): 439a CONTENTS PETROLEUM: AR UNLEADED [3 lc.MIDGRADE UNLEADED [I lb.PREMIUM UNLEADED 440 3.DIESE ❑ 5.JET FUEL ❑ 6.AVIATION GAS 8.PET OLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 IV.`TANK-CONSTRUCTION TYPE OF TANK ❑ .SINGLE WALL Cff 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT E3 1.STEEL Er3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT Q'1.STEEL FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S ec ): 445a OVERFILL PREVENTION 1.AUDIBLE Bc VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. !LR ODU T/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ INGLE-WALLED 2.DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE Iff 1.PRESSURE IJ 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 ❑ 0.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT EN 1.STEEL Rr4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ ?2.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE WI.SINGLE WALL L 2.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECOVERY(YR)AND RISER/FELL.PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS El 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 0 99.OTHER(Specify) 4648 464 I VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE 1.SINGLE W"' .• 1.DOUBLE WALL 0.NONE 4641. RISER PRIMARY CONTAINMENT Edl.STEEL FT'ERGLASS 11 10.RIGID PLASTIC ❑ 90.NONE El 99.OTHER(Specify) 464] 464'1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL Wd,4.FIBERGLASS 10.RIGID PLASTIC (37§f NONE 0 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 45la-e VII.UNDER DISPENSER 1CONTAINMEw.(UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL U 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bc VIII. CORROSION;PROTECTION STEEL COMPONENT PROTECTION [ 1.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 compliance with legal requirements. APPLICANT SIGNATU DATE - 470• 1 APPLICANT NAME(prin) 111 � 471' APPLICANT TITLE 472• - Imo// � UPCF UST-B-1/2 / Rev.(12/2007)