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a r-1 UM&IED PROGRAM CONSOLIDATED FORNP UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (one form per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal, complete only this section and Sections 1, A III, IV, and IX below) 430. ❑ 1. NEW PERMIT ® 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 430b. L FACILITY INFORMATION ID#(Age ncy Use Only) 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 II. TANK DESCRIPTION TANK ID # (1y D Z h 432. _ V 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 III. TANK USE AND CONTENTS TANK USE ® Ia. MOTOR VEHICLE FUELING ❑ lb. MARINA FUELING ❑ lc. AVIATION FUELING 439. ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 5. EMERGENCY GENERATOR FUEL [HSC §25281.5(.)] ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439& CONTENTS PETROLEUM: ❑ Ia. REGULAR UNLEADED ❑ lc. MIDGRADE UNLEADED ® Ib. PREMIUM UNLEADED 440- 0 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (Specify): 440& _❑_ NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ❑ 11. OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CO "RIJ II►N TYPE OF TANK _ ❑ 1. SINGLE WALL ® 2. DOUBLE WALL ❑ 95. UNKNOWN 443. �IQ PRIMARY CONTAINMENT ❑ 1. STEEL 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444. ❑ 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ I. STEEL ® 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445. _ ❑ 90. NONE ❑ 95. UNKNOW_ N ❑ 99. OTHER (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 [WASTE PIPING CONSTI�� PIPING CONSTRUCTION ❑ 1. SINGLE WALL ®_2. DOUBLE WALL [399.OTHER 460. SYSTEM TYPE ® I. PRESSURE ❑ 2. GRAVITY _ ^ ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION_ [23 CCR §2636(aX3)] 458. PRIMARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS- ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464. ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464& SECONDARY CONTAINMENT ❑ I. STEEL ® 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464b. ❑ 90. NONE _ ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464c. PIPING/TURBINE CONTAINMENT SUMP TYPE ® 1. SINGLE WALL [32. DOUBLE WALL El 90. NONE 4644. VL IM VAPOR RECt} E} ANTI RISER OW PIPE PIPING CONSTI IT N VENT PRIMARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE [199.OTHER (Specify): 4� 90. NONE ❑ 99. OTHER (Specify): 4 VENT SECONDARY CONTAINMENT. ElL STEEL ❑ 4. FIBERGLASS [310. RIGID PLASTIC ® 646 VR PRIMARY CONTAINMENT ❑ L STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE` ❑ 99. OTHER (Specify): 4464 . VR SECONDARY CONTAINMENT [3L STEEL ❑ 4. FIBERGLASS [110. RIGID PLASTIC ® 90. NONE �❑ 99. OTHER (Specify): 464hl. l. VENT PIPING TRANSITION SUMP TYPE ❑ 1. SINGLE WALL ❑ 2. DOUBLE WALL ® 90. NONE moi' 464]. RISER PRIMARY CONTAINMENT ® 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 464*1. RISER SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ® 90. NONE ❑ 99. OTHER (Specify): 464ki. FILL COMPONENTS INSTALLED ® 1. SPILL BUCKET ® 3. STRIKER PLATE/BOTTOM PROTECTOR ❑ 4. CONTAINMENT SUMP 45la-c. VII. UNDER DISPENSER CONTAINMENT ((W) CONSTRUCTION TYPE ® 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 469x. CONSTRUCTION MATERIAL ❑ 1. STEEL ❑ 4. FIBERGLASS ® 10. RIGID PLASTIC ❑ 99, OTHER (Specify)-___.____.____.�_.- 4�_ ' . ,I~P$** N PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANOD S ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION 448. WAPPLIOMT SIGNATURE 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 legal requirements. APPLICANT SIGNATURE env' '-/ DATE J p C� 470. APPLICANT NAME (print) fiafi Kamboj 471. APPLICANT TITLE Partner 472. UPCF UST -B Rev. (12/2007) -1/2 www.unidocs.org