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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 UST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 430 <br /> ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT 9-5.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) 1 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 <br /> ei-4r (25c- C:?P. 11-4 C -- <br /> BusINEDREss crrY w�� �_ ��G�..� 104 <br /> H.TANK DESCRIPTION <br /> TANK ID# G.-3 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 <br /> l7 p�Gi L f� <br /> [11.A STAND-ALONE TANK <br /> )C _ RZ.ONE IN A COMPARTMENTED UNIT. <br /> Complete one pow for each cmmurunew in the unit. <br /> DATE UST&Y STALLED 435 TANK CAPACCITY IN GALLONS 436 NUMBER OF COMP TMENTS IN THE UNIT 437 <br /> III.TANK USE AND CONTENTS <br /> TANK USE e-la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ ic.AVIATION FUELING 439 <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑4.HAZARDOUS WASTE(indudes Used Oip ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a <br /> CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ 1b.PREMIUM UNLEADED 440 <br /> P9-3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 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 ❑ 1.SINGLE WALL .DOUBLE WALL ❑ 95.UNKNOWN 443 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL ,.3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Sci ): 444a <br /> SECONDARY CONTAINMENT ❑ L STEEL �FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER L17.JACKETED 445 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a <br /> OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS llk2.BALL FLOAT G9,3.FILL TUBE SHUT-OFF VALVE 452. <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V PRODUCT/WASTEPIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑1.SINGLE-WALLED M.DOUBLE-WALLED [199.OTHER 460 <br /> SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL R3J.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specif3r): 464a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL JU-4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464e <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE ELI.SINGLE WALL ❑2.DOUBLE WALL ❑ 90.NONE 464d <br /> VI:VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT 0 1.STEEL a 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE Lj 99.OTHER(Specify) 464e <br /> 464el <br /> VENT SECONDARY CONTAINMENT, ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ".NONE ❑ 99.OTHER(Specify) 464E <br /> 464f1 <br /> VR PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC R,90.NONE 0 99.OTHER(Specify) 4648 <br /> VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC P_90.NONE E399.OTHER(Specify) 4464h <br /> 464hl <br /> VENT PIPING TRANSITION SUMP TYPE Q 1.SINGLE WALL Q 2.DOUBLE WALL NONE 4641. <br /> RISER PRIMARY CONTAINMENT El L STEEL 4.FIBERGLASS Ll 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 464j <br /> 464'( <br /> RISER SECONDARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS 10.RIGIDPLASTIC 90.NONE 99.OTHER(Specify) 464k <br /> 464kt <br /> FILL COMPONENTS INSTALLED1.SPILL BUCKET W3.STRIKER PLATEtBOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 451ac <br /> VII.UNDER"DISPENSERCONTAINMENT.(UDC). ' <br /> CONSTRUCTION TYPE IZU.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a <br /> CONSTRUCTION MATERIAL STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bc <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 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 provided herein Is true,a urate, <br /> and in full compliance with legal requirements. °��'"` <br /> APPLI SIGNATURE DATE 470. <br /> AF(PLIC N rmt) 471' APPLICANT TITLE 4n. <br /> UPCF UST-B-1/2 <br /> Rev.(124063 <br />