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i 0 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) <br /> TYPE OF ACTION (Check one item only. For an ST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 430 <br /> ❑ 1.NEW PERMIT O3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430a I DATE EXISTING UST DISCOVERED: 4306 <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) yy _ _ Y 1 <br /> /'T V ( U <br /> BUSINESS N (Same as FACILITY N AME o;DBA-Doing Business As) 3 <br /> BUSINESS Srr9 ADDRESS 103 CITYi� y� 104 <br /> H.TANK DESCRIPTION F <br /> TANK ID# "" TANK MANUFACTURER 433 TA r ONFIGURATION:THIS TANK IS 434 <br /> /� ( STAND-ALONE TANK <br /> / I I ✓, ❑ <br /> 2.ONE IN A COMPARTMENTED UNIT. <br /> w Complete one page for each compartment in the unit. <br /> DATE UST SZM INSTALLED 435 TANK CAPACITY IN G,4LLONS 436 NUMBER OF COMP TMENTS IN THE UNIT 437 <br /> U <br /> III.TANK USE AND CONTENTS' <br /> TANK USE Yla.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439 <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ ?,2,OTHER(Specify): 439a <br /> CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED lb.PREMIUM UNLEADED 440 <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ <br /> 11.OTHER NON-PETROLEUM(Specify): 4406 <br /> IV. TANK-CONSTRUCTION <br /> TYPE OF TANK ❑ INGLE WALL Eff 2.DOUBLE WALL ❑ 95.UNKNOWN 443 <br /> PRIMARY CONTAINMENT U L STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 <br /> ❑ 7.STEEL+INTERNAL INING ❑ 95.UNKNOWN ❑ 99.OTHER (S ): 444a <br /> SECONDARY CONTAINMENT t.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 <br /> ❑ .NONE ❑ 95.UNKNOWN [199.OTHER(S ): 445a <br /> OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODU T_%WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION SINGLE-WALLED r72.DOUBLE-WALLED ❑99.OTHER 460 <br /> SYSTEM TYPE 1,PRESSURE <br /> u,.4.GRAVITY [13.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(ax3)] 458 <br /> PRIMARY CONTAINMENT [t I.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 <br /> ❑ 90.NONE ❑ ?,5.UNKNOWN ❑ 99.OTHER(Specify): 464a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 <br /> ❑ 90.NONE ❑25.UNKNOWN ❑ 99.OTHER(Specify): 464c <br /> PIPING[I'URBINE CONTAINMENT SUMP TYPE Iff 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 4644 <br /> VI.VENT,VAPOR RECO (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION: <br /> VENT PRIMARY CONTAINMENT LJ 1.STEEL En 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464c <br /> 464e1 <br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL Y.FIBERGLASS ❑ 10.RIGID PLASTIC a90.NONE ❑ 99.OTHER(Specify) 464f <br /> 464fl <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL GrZ FIBERGLASS ❑ 10.RIGID PLASTIC [j 90.NONE ❑ 99.OTHER(Specify) 4648 <br /> 464 1 <br /> VR SECONDARY CONTAINMENT ❑ 1.STEELFIBERGLASS ❑ 10.RIGID PLASTIC 090.NON] 19.OTHER(Specify) 464h <br /> 464hl <br /> VENT PIPING TRANSITION SUMP TYPE 0,1.SINGLE WALL v 2.DOUBLE WALL 90.NONE 4641. <br /> RISER PRIMARY CONTAINMENT MI 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 464) <br /> 464'1 <br /> RISER SECONDARY CONTAINMENT 1.STEEL4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464k <br /> 464k1 <br /> FILL COMPONENTS INSTALLED W, SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 45la-c <br /> `VII.UNDER DISPENSER CONTAINMENT.(UDC) <br /> CONSTRUCTION TYPE 1.SINGLEWALL F32.DOUBLE WALL [33.NO DISPENSERS [:190.NONE 469a <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b•c <br /> VIII.CORROSION-PROTECTION <br /> STEEL COMPONENT PROTECTIONS 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information p rein is true,accurate, <br /> and in full com Bance with legal requirements. "r <br /> APPLICANT SIGNATU1pfDATE °' 470• <br /> APPLICANT N rint) • 6-- 471' APPLICANT TITLE472. <br /> .a <br /> UPCF UST-B-1/2 �� <br /> Rev.(12/200'n <br /> t� ` 3 V'j 13-N <br />