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4.. UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UsT) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this s�ectyi wand Sections I,II,III,IV,and IX below) 430 [11.NEW PERMIT [13.RENEWAL PERMIT If 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 FACILITY ID#(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 N0 C,A9 BUSINESS SITE ADDRESS 103 CITY 104 o . �!1c5c�to P. L-03L II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TA CONFIGURATION:THIS TANK IS 434 ASTAND-ALONE TANK M o D t,rZ>J t�rsr N ❑2.ONE INA COMPARTMENTED UNIT. Complete one pop for each cmnpmftcw in the ufdt. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 III.TANK USE AND CONTENTS TANK USE M la.MOTOR VEHICLE FUELING ❑ ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Indudes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC 125281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ 13,REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ 1b.PREMIUM UNLEADED 440 DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4401 IV. TANKCONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL EV2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS [16.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify)- 445a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT ET3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑I.-SINGLE-WALLED .DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE I.PRESSURE ❑2.GRAM Y ❑ 3.CONVENTIONAL SUCTION ❑4.SAFE SUCTION[23 CCR§2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ L STEEL .FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95 OWN ❑ 99.OTHER(Specify): 464. PIPING/TURBINE CONTAINMENT SUMP TYPE LYI.SINGLE WALL ❑2.DOUBLE WALL ❑ 90.NONE 4Md VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 1.STEEL EF4FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464c 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464f 464fl VR PRIMARY CONTAINMENT ❑ 1.STEEL WT FIBERGLASS El 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464g 464 I VR SECONDARY CONTAINMENT ❑ (.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC EV9,0.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC El 90.NONE 0 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT 0 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC 0 V.NONE 0 99.OTHER(Specify) 464k 4641 FILL COMPONENTS INSTALLED SPILL BUCKET 943.STRIKER PLATEBOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 451a-c .UNDER DISPENSER CONTAINMENT.(UAC} CONSTRUCTION TYPE UkI.SINGLE WALL [12.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL Gr4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4691,c VIII. CORROSION-PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑4.IMPRESSED CURRENT ❑ 6.ISOLATION 448• IX. APPLICANTSIGNATURE CERTIFICATION: I certify that this UST sy is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full compliance eral reauirements. APPLICANT SIGNATURE DATE �� 470; w ; APPLICANT NAME(print) 471' APPLICANT TITLE 472. r UPCF UST-H-?/Z ` Rev.(12/2007)