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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERAUT 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,andlx below) 430 ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 0 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 430b L FACHJTY INFORMATION 1 FACILITY ID#(Agency Use Only) - - BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 ton BUSINESS SITE ADDRESS yo to3 CITY H.TANK DESCRIPTION TANK ID# /� TANjC MANUFACTI)RER 433 TANK CONFIGURATION:Tms TANK IS 434 l '4 A STAND-ALONE TANK � 2.ONE 1N A COMPARTMENTED UNIT. one pw fm each convabowt in On gait DATE U.St1' S STALLED 435 TANK CAPAC �I ALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 `,( IRTANANK USE AND CONTENTS TANK USE a.MOTOR VEHICLE FUELING E3 1b.MARINA FUELING [3 1 c.AVIATION FUELING a39 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(k-b-"Used Oil) ❑ 5.EMERGENCY GElERATOR FUEL[HSC§25281.5(c)) [16.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑99.OTHER( 439a39a CONTENTS PETROLEUM: ❑ Is.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ 1b.PREMfUMUNLEADED 440 ❑ 3.DIESEL Q 5.JET FUEL [16.AVIATION GAS' ,_ a4oa ❑ 8.PETROLEUM BLEMFUEL .ammPEnwLEUM S ' %,0c� NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 440b 11.OTHER NON-PETROLEUM IV. TANK CONSTRUCTION 443 TYPE OF TANK 1.SINGLE WALL DOUBLE WALL ❑ 95.UNKNOWN PRIMARY CONTAINMENT STEEL ❑ 3.FIBERGLASS ❑6.INTERNAL BLADDER 444 STEEL+INTERNAL LINING ❑95.UNKNOWN E399.OTHER : 444a Ti a SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ExTERIOR MEMBRANE LINER ❑ 7.JACKEPED 445 90.NONE ❑ 95.UNKNOWN 99.OTHER 445a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS U 2.BALL FLOAT 3.FII L TUBB SHUT-0FF VALVE 452 ❑ 4.TANK MEETS REQUIREMENTSFOR-HU PTtONFROMOVERFIII ON EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑L sINGLE-wALLED DOUBLB wALLED E399-OTHER 458 SYSTEM TYPE .PRESSURE ❑ 2.GRAVITY [13.CONVENTIONAL SUCTION 4.SAFE SUCTION 73 CCR 636(a)(3 458 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.nEKIRT.R ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN (399.0 464a SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEMBLE ❑ 10.RIGIDPLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER S ): 444c PIPINGITURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL Q 2.DOUBLE WALL ❑ 90.NONE VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT U 1.STEEL j9L4.FIBERGLASS U 10.RIGIDPLASTIC 13 90 NONE IT99.OTHER(SpectfY) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS 10.RIGID PLASTIC NONE ❑ 99.OTHER(Specify) 464f 46441 VR PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑90.NONE 0 99 OTHER(Specify) 4645 t VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 1Q RIGID PLASTIC 090.NONEIff 99.OTHER(Specify) 46411 464h1 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 0 2.DOUBLE WALL NONE 464, RISER PRIMARY CONTAUgMtINT .STEEL4.FIBERGLASS 10.RIGID PLASTIC U W NONE 0 99.OTHER(Specify) 46/i RISER SECONDARY CONTAINMENT 1.STEEL Ij 4.-FIBERGLASS 0 1 Q RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464h 464k1 FILL COMPONENTS INSTALLIDI.SPILL BUCKET 1t .STRUCPLATFJBOTTOMPRCTECfOR 4.CONTAINMENT SUMP 45tac VIL UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYM 11,L SINGLE WALL ❑2.DOUBLE WALL ❑3.NO DISPENSERS ❑90.NONE CONSTRUCTION MATERIAL ❑ 1.STEEL FIBERGLASS 0 10 RIGID PLASTIC U 99.O1HER ) 4e9b c VU1 CORROSION PROTECTION 449 STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑4.IMPRESSED,CURRENT ❑ 6.ISOLATION IX. APPLICANT SIGNATURE CERTIFICATION: I cerH at his UST system is compatible with the hazardous substance stored and that the information provided heteia is true,accurate, ' and ult Dance with legat Muirements. 470. APPLICANT SIGNATUY ( DATE 471. APPLICANT 472. APPLICANT NAME"' ) Rev.(12/2007) UPCF UST-B-1/2 r