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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) <br /> TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only thissect[ and Sections I,II,III,IV,and IX below) 430 <br /> [11.NEW PERMIT 1--] 3.RENEWAL PERMIT L7 �•CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 430b <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) i <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 <br /> �N0 AS <br /> BUSINESS SITE ADDRESS s,,?(9 I CTC) �� ` 103 CITY L��� 104 <br /> H.TANK DESCRIPTION <br /> TANK ID# \r F 432 TANK MANUFACTURER 433 TA CONFIGURATION: THIS TANK IS 434 <br /> ! D �^S ONE STAND-ALONE <br /> G/ OMPARTMENTED UNIT. <br /> " <br /> complete one PAP for each WMPMMMM in the urdL <br /> DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 <br /> 1 oo 0 <br /> III.TANK USE AND CONTENTS <br /> TANK USE gr la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING <br /> ❑ ]c.AVIATION FUELING 439 <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] <br /> 06.OTHERGENERAT RFUEL [:] 95.UNKNOWN [399.OTHER(Specify): 439a <br /> CONTENTS PETROLEUM: WIa.REGULAR UNLEADED ❑ la MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ <br /> S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (specify): 440a <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ <br /> 11.OTHER NON-PETROLEUM(Specify): 440b <br /> IV.',TANK.CONSTRUC TION <br /> TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑95.UNKNOWN 443 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL W3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S ): 444a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify) 445a <br /> OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑1.SINGLE-WALLED al DOUBLE-WALLED ❑99.OTHER 460 <br /> SYSTEM TYPE Ulf.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(ax3)] 458 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL br4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL GY4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 4646 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE Erl.SINGLE WALL ❑2.DOUBLE WALL ❑ 90.NONE 464d <br /> VI.VENT,VAPOR;RECOVERY(VR).AND RISER/FILL;PIPE-PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT U 1.STEEL W4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464e <br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 010.NONE ❑ 99.OTHER(Specify) 464f <br /> 46411 <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL 034.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 464g <br /> 464 1 <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 9 9o.NONE ❑ 99.OTHER(Specify) 464h <br /> 464h1 <br /> VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL .NONE 4641. <br /> RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC T%.NONE 99.OTHER(Specify) 464j <br /> 464'1 <br /> RISER SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 0 10.RIGIDPLASTIC 90.NONE ❑ 99.OTHER(Specify) 464k <br /> 464k1 <br /> FILL COMPONENTS INSTALLED ErI.SPILLBUCKET ffel STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 45la•c <br /> VII.UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL [33.NO DISPENSERS ❑ 90.NONE 469a <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑99.OTHER(Specify) 469bc <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) [14.IMPRESSED CURRENT ❑ 6.ISOLATION 448. <br /> M APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST y tem is compatible with the hazardous substance stored and that the information provided herein is trues accurate, <br /> and in full comeftEj wi h legal requirements. <br /> APPLICANT SIGNATURE a DATE C � r �i 470. <br /> APPLICANT NAME(print) 471' APPLICANT TITLE 4 472. <br /> UPCF UST-B-t/Z <br /> now.(IZ/18B'n <br />