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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. For an UST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 430 ❑ I.NEW PERMIT {R 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: IV 14- 430a DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ _ 7 4 I 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 BUSINFASS SITE DRESS 103 C toa r ^ H.TANK DESCRIPTION TANK ID J gg C) - 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 f , I31.A STAND-ALONE TANK TRS �� [12.ONE IN A COMPARTMENTED UNIT. Complete one for each compm1mentinthe mdt. DATE UST SYSTEM INSTALLED 435 TANK CAaAGITY IN GALLONS 436 NUMBER OF r_nMPARTMENTS IN THE UNIT 437 190 MAW 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(lndudes Used Oa) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: Off 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 (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 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT1.STEEL 3.FIBERGLASS [16.EXTERIOR MEMBRANE LINER [37.JACKETED 445 E3 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS ` 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUMEMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ SINGLE-WALLED EIM DOUBLE-WALLED (199.OTHER 460 SYSTEM TYPE 10 I.PRESSURE M&4. (13.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(ax3)] 458 PRIMARY CONTAINMENT L 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ .UNKNOWN ❑99.OTHER(Specify): 464c PIPING/I'URBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL L 2.DOUBLE WALL ❑ 90.NONE 464d VL VENT,VAPOR RECOVERY(VR)AND RISER/FELL.PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT Ll 1.STEEL Eff 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE D 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL Er 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑90.NONE ❑ 99.OTHER(Specify) 464E VR PRIMARY CONTAINMENT ❑ 1.STEEL Mr 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 464g 464 I VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC464h1 ❑ 9 .NONE 99.OTHER(Specify) 464h VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WAL 2.DOUBLE WALL 90.NONE 464L RISER PRIMARY CONTAINMENT Pn.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464i 464'1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL 44.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464k FILL COMPONENTS INSTALLED 1.SPILL BUCKET LJ 3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT IUDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL Er 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469be VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION c.SACRIFICIAL ANODE(S) [14.IMPRESSED CURRENT 6.ISOLATION "v 448• IX. APPLICANT SIGNATURE : CERTIFICATION: I certify that this UST sPystem is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full compliance with legal requirements. APPLICANT SIGNATURE DATE azo. APPLICANT NAME rt) 411. APPLICANT TITLE 472. 4 PIP, UPCF UST-B-1/2 Rev.(12/2007) v � 117()1 3 ,,,)