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IED PROGRAM CONSOLIDATED FO UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION -TANK INFORMATION (One form per UST) YPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections!,!!,!!!,!V,and!X below) 430. ❑ L NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION l ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a. I DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) - - cf c? 1 BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3 Cr 14A4 T)?q 14 AAT G-AS 9--'Lrrn BUSINESS SITE ADDRESS ^ 103. CITY ,f 9 5-3 -3 / 104 II. TANK DESCRIPTION TANK ID# 43' TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. /� G� ❑ 1.A STAND-ALONE TANK Complete one page for each (i' ��t-� �'�..- ``'�� 2.ONE IN A COMPARTMENTED UNIT compartment in the unit. DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. - S 6 #0 O -TtsD III. TANK USE AND CONTENTS TANK USE 1% 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(c)] --�6.OTHER GENERATOR FUEL____._----_0_95.UNKNOWN - -- -- 0_99_OTHER(Specify): 439a. CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED IQ Ib.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUMBLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440a. --------- ......_.. ....... .._...- -- --- - - - NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL J0 2.DOUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT ® 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN 0 99.OTHER(Specify): 444a. SECONDARY CONTAINMENT ❑ I.STEEL ER 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE--- ❑ 95.UNKNOWN [199.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 CONSTRUCTION PIPING CONSTRUCTION 0 1.SINGLE WALL 9 2.DOUBLE WALL ❑ 99.OTHER 460. -- - ----- - -- -- - --.. --- ......... -- - SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3 CONVENTIONAL SUCTION_ [14.SAFE SUCTION f23 CCR§2636(a)(3)]- 458. PRIMARY CONTAINMENT 111.STEEL J� 4.FIBERGLASS ❑ 8.FLEXIBLE [310.RIGID PLASTIC aha. ❑ 90.NONE El 95.UNKNOWN -_.0 99.OTHER(Specify): 464a. SECONDARY CONTAINMENT (] 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. PIPING/TURBQYE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d. VI. VENT,VAPOR RECOVERY(VR) AND RISER/FILL PIPE PIPING CONSTRUCTION 464e. VENT PRIMARY CONTAINMENT ❑ 1.STEEL r9 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464el. 464f. VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC N 90.NONE ❑ 99.OTHER(Specify): 464fl -----_._..._.__ -- 464g. VR PRIMARY CONTAINMENT ❑ 1.STEEL Qj 4.FIBERGLASS ❑ 10.RIGID PLASTIC-- [390.NONE [:199.OTHER(Specify): 464 I. --- _ --..._..........__._._. _.._.. --- VR SECONDARY CONTAINMENT 0 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC .50 90.NONE ❑ 99.OTHER(Specify): 464h1. --- - - ------------- -- _-- _........ ._...---- - -- VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 4�` 464j. RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4641. 464k. RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464kl. FILL COMPONENTS INSTALLED 1.SPILL BUCKET JR 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE _ _I.SINGLE WALL ❑ 2_DOUBLE WALL_ 0 3.NO DISPENSERS 0_90_NONE 469a. 4696. CONSTRUCTION MATERIAL ❑ L STEEL ER 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT JU 6.ISOLATION 448. IX. APPLICANT 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. l "�- azo. APPLICANT SIGNATURE -7'rte DATE �j -� - APPLICANT NAME(print) NS -r s) Al SIS 471. APPLICANT TITLE ��s s� Q n/ 472. UPCF UST-B Rev.(12/2007)-1/2 www.unidoes.org