COMPLIANCE INFO_2007-2016 - Laserfiche WebLink

Home Browse Search

fib AIL U IFIED PROGRAM CONSOLIDATED FORW UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (One form per UST) TYP;0FACTION (Check one item only. For a UST closure or removal, complete only this section and Sections I, 11, III, IV,, and IX below) 430. ❑ 1.RMIT ® 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 430x. I DATE EXISTING UST DISCOVERED: 430b. I FACILITY IMO iii FACILITY ID # (Agency Use Only) i• BUSINESS NAME (Same as Facility Name or DBA - Doing Business As) 3. One Stop Market BUSINESS SITE ADDRESS 103. 1151 W. Louis Ave CITY 104. Mateca TANK DESCRIPTION TANK ID # O 1 D 432. TANK MANUFACTURER 433. UK TANK CONFIGURATION: THIS TANK IS 434. ® 1. A STAND-ALONE TANK Complete one page for each ❑ 2. ONE IN A COMPARTMENTED UNIT compartment in the unit. DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. 10,000 NUMBER OF COMPARTMENTS IN THE UNIT 437. 0 M. TANK USE AND CONTENTS TANK USE N Ia. MOTOR VEHICLE FUELING ❑ 1b. MARINA FUELING ❑ lc. AVIATION FUELING 439. ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (includes Used Oil) ❑ 5. EMERGENCY GENERATOR FUEL [HSC §25281.5(c)] ❑ 6. OTHER GENERATOR FUEL 95. UNKNOWN ❑ 99. OTHER (Specify): 439a. _❑_ CONTENTS PETROLEUM: ® la. REGULAR UNLEADED ❑ 1c. MIDGRADE UNLEADED ❑ 1b. PREMIUM UNLEADED 440. ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTTER PETROLEUM (Specify): 440x. _ NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ❑ 11. OTHER NON -PETROLEUM (Specify): 440b. IV. TANS CONS`i"RI7"ION TYPE OF TANK _ ❑ 1. SINGLE WALL ® 2. DOUBLE WALL ❑ 95. UNKNOWN 443. PRIMARY CONTAINMENT ❑ 1. STEEL a 3. FIBERGLASS ❑ 6. INTERNAL BLADDER ❑ 7. STEEL +INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 444x. _ _ SECONDARY CONTAINMENT ❑ 1. STEEL ® 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER _ ❑ 7. JACKETED 445 _ ❑ 90. NONE ❑ 95. UNKNOWN [199. OTHE_R (Specify): 445a. OVERFILL PREVENTION ® 1. AUDIBLE & VISUAL ALARMS ® 2. BALL FLOAT ❑ 3. FILL TUBE SHUT-OFF VALVE 452. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT 1 WASTE PIPING CONSTRUCTI }N PIPING CONSTRUCTION ❑ 1. SINGLE WALL ® 2. DOUBLE WALL ❑ 99. OTHER 460. TYPE ® 1. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR §2636(ax3)) _ 458. _SYSTEM PRIMARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464. ❑ 90. NONE _ ❑_ UNKNOWN ❑ 99. OTHER (Specify): 464a• _95. SECONDARY CONTAINMENT ❑ i. STEEL ® 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC T464b. ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464c. PIPING/TURBINE CONTAINMENT SUMP TYPE ® 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE 4644. VI. VENT, VAPOR RECOVERY R) ANII RI f FILL PIPE PIPING CONSTkOttiON VENT PRIMARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 46 e VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ® 90. NONE [199. OTHER (Specify): 464n464f. VR PRIMARY CONTAINMENT ❑ I . STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): =81 VR SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ® 90. NONE ❑ 99. OTHER (Specify): 464441. VENT PIPING TRANSITION SUMP TYPE ❑ 1. SINGLE WALL ❑ 2. DOUBLE WALL ® 90. NONE4i RISER PRIMARY CONTAINMENTT N 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC _ ❑ 90. NONE ❑ 99. OTHER (Specify): 4644 j RISER SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ® 90. NONE` ❑ 99. OTHER (Specify): 4644hi, FILL COMPONENTS INSTALLED N 1. SPILL BUCKET N 3. STRIKER PLATE/BOTTOM PROTECTOR ❑ 4. CONTAINMENT SUMP 45la-c. VII. UNDER DW"ER CONTAINMENT (UDC) CONSTRUCTION TYPE N 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE I69a. CONSTRUCTION MATERIAL ❑ 1. STEEL ❑ 4. FIBERGLASS ® 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 469c: VIII. CORROSION PROTECT STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANOD S ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION 448. IX. APPLICANT SIGNATU" CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate, and in full compliance with 1 al requirements. APPLICANT SIGNATURE DATE 470. APPLICANT NAME (print) Hari K=boj 471. APPLICANT TITLE Partner 472. UPCF UST -B Rev. (12/2007) -1/2 www.unidoes.org