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Ah AM IFIED PROGRAM CONSOLIDATED FORW UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. ForS US pelmanent closure or removal complete only this section and Sections I,II,III,IV,and IX below) 430 LJ 1.NEW PERMIT I'- ❑ 5.CHANGE OF INFORMATION 6. �] TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 41 DATE EXISTING UST DISCOVERED: 430b FACILITY ID#(Agency Use Only) L FACILITY INFORMATION I - - 3 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) ^w a_ BUSINESS SITE ADDRESS,,7^ 103 (CI j Y ^a A 104 LV H.TANK DESCRIPTION TANK ID# TANK Mt1NUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 1.A STAND-ALONE TANK ❑2.ONE IN A COMPARTMENTED UNIT. J\ cmpiewone pay for eaa comPamad in the mit DATE UST SYS IN TALLED 435 TANK CAPAcT OGALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT t a3� 0_100 IIL TANK USE AND CONTENTS 1 TANK USE a.MOTOR VEHICLE FUELING [I 1b.MARINA FUELING El lc.AVIATION FUELING 439 [13.CHEMICAL PRODUCT STORAGE E] 4.HAZARDOUS WASTE(IneWa Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] 439a ❑ 6.OTHER GENERATOR FUEL [195.UNKNOWN ❑ 99.OTHER(Specify): 440 CONTENTS PETROLEUM: Nkja REGULAR UNLEADED ❑ Ic.MIDGRADEUNLEADED ❑ Ib.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS 440a ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 440b I I:OTHERNON-PETROLEUM S IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL It 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT JU.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ L STEEL ❑3.FIBERGLASS jff4,EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHERS i 445a OVERFILL PREVENTION I.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE PRESSURE [12.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR§2636(-x3)] 458 PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 I ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTBER(S ify): 464a SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE 95-UNKNOWN ❑ 99,OTHER(Specify): a4 Baa PIPING(rURBINE CONTAINMENT SUMP TYPE I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT U I.STEEL jj,4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 4664e14el VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10-RIGID PLASTIC .NONE ❑ 99.OTHER(Specify) 664E 464fl VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99-OTHER(Specify) 464L 4641LI VENT PIPING TRANSITION SUMP TYPE AAWSINGLEWALL 0 2.DOUBLE WALL 90.NONE a6 RISER PRIMARY CONTAINMENT .STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464jj 1 RISER SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED SPILL BUCKET W3.STRIKER PLATRIBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 4516 VIL UNDER D ISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE __S WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 4696 CONSTRUCTION MATERIAL L] 1.STEEL 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 99.OTHER(Specify) 6696-c VIII. CORROSION PROTECTION aaa. STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.1MPRESSED CURRENT ❑ 6.ISOLATION 'r IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information prove,accurate, and in Dance with le al r uirements. azo. DATE ' APPLICANT SIGNA / v 471. 472. APPLICANT NAME(print) APPLICANT TITLE R,1 Rev.(12/2007) UPCF UST-B-1/2