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UXIFM PROGRAM CONSOLIDATED FORW III b (I Z UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (0m fo-m m Usl) TYPE OF ACTION (Check ane item maty. For a UST ctosuae or nemova4 compk a only this sectma and Sections I, 11, 111,1 Y; 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: 43QL I DATE EXISTING UST DISCOVERED. 43M- „,. FACILITY ID # (Agency Use Only) I'll A 6 ( L Y BUSINESS NAME (Same as Facility Name or DBA - Doing Business As) fT( One Ston Market 103. 1151 W. Louis Ave �.. V. PRODUCT/ WASTE PIPING C f $OIJMON , PIPING CONSTRUCTION ❑ 1. SINGLE WALL ® 2. DOUBLE WALL ❑ 99.OTHER 460. SYSTEM TYPE ® L PRESSURE ❑ 2. GRAVITY ❑ 3- CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR §2636(aJ(3R 458. PRIMARY CONTAINMENT ❑ 1. STEEL. ® 4. FIBFLEXIBLE ❑ 8.FXIB F E310. RIGID PLASTIC ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHFR (Specify): 464& TANK USE ® Ia. MOTOR VEHICLE FUELING ❑ lb. MARINA FUELING ❑ Ic. AVIATION FUELING 439. ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (mdo" used oil) 05 , 5. EMERGENCY GENERATOR FUEL [HSC §25281.5(e)] [36.OTHER GENERATOR FUEL ❑ 95. UNKNOWN 1399.OTHER (Specify): 439& CONTENTS PETROLEUM: ❑ la. REGULAR UNLEADED ❑ is MIDGRADE UNLEADED 0 Ib. PREMIUM UNLEADED 440. ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (Specify). 440& NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL j �.. V. PRODUCT/ WASTE PIPING C f $OIJMON , PIPING CONSTRUCTION ❑ 1. SINGLE WALL ® 2. DOUBLE WALL ❑ 99.OTHER 460. SYSTEM TYPE ® L PRESSURE ❑ 2. GRAVITY ❑ 3- CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR §2636(aJ(3R 458. PRIMARY CONTAINMENT ❑ 1. STEEL. ® 4. FIBFLEXIBLE ❑ 8.FXIB F E310. RIGID PLASTIC ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHFR (Specify): 464& 464. SECONDARY CONTAINMENT ❑ I . STEEL ® 4- FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464c. 464b. PIPINGII'URBINE CONTAINMENT SUMP TYPE 0 1. SINGLE WALL ❑ 2_ DOUBLE WALL ❑ 90. NONE 464& VL VENT, VA�UCOVERY (VR) A" RISER /FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1. STEEL N 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 464e. 464e1 VENT SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ® 90. NONE ❑ 99.OTHER (Specify): 464417 VR PRIMARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 4g' 46aQ1 VR SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC N 90. NONE ❑ 99. OTHER (Specify): 464h. 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ 1. SINGLE WALL. ❑ 2. DOUBLE WALL ® 9o. NONE 4641. RISER PRIMARY CONTAINMENT ® 1. STEEL ❑ 4. FIBERGLASS [3 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): j RISER SECONDARY CONTAINMENT E]1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ® 90. NONE [399.OTHER (Specify): 46411. FILL COMPONENTS INSTALLED ® 1. SPILL BUCKET ® 3. STRUWA PE.KI>~MOTIOh1 PROTECTOR ❑ 4. CONTAINMENT SUMP 45]a -c,- r . VII. ` I3hTDER DI3ITER e81't'AiNI. CONSTRUCTION TYPE ® L SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3_ NO DISPENSERS ❑ 90. NONE 469a. CONSTRUCTION MATERIAL ❑ 1. STEEL ❑ 4_ FUIERGLASS Cl 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 469b. 469c. STEEL COMPONENT PROTECTION 4. RASI ❑ 2 SACRIFICIAL ANOi iS) ❑ EI SED CURRENT 6 ISOLATION '77 448 CERTIFICATION: I certify that this USP systemis Coalpatible wilt, the basardom substaice stored and that the iaferme ion:provided herein is true, accurate, and in fait compliance with APPLICANT SIGNATURE Gv' ' �r DATEJ 1 4700. APPLICANT NAME (print) Aarl Kamboj 471. APPLICANT TITLE Partner 472. UPCF UST -B Rev. (122007) -12 www.unidocs_org