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P.6 of <br /> IIFIED PROGRAM CONSOLIDATED FC <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 this section and Sections 1,Il,III,]V;and IX below) 430 <br /> © L NEW PERMIT 0 3.RENEWAL PERI11T ❑ 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 43"" DATE EXISTING UST DISCOVERED: I a306 <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Onh) - ;o 1 <br /> � - <br /> BUSINESS NAME(Sam as FACILITY E or DBA-Doing Bus' css As) F D O © s' i 3 <br /> BUSNESS SITE ADDRESS103 CITY F 1' <br /> to r <br /> II.TANK DESCRIPTION <br /> TANK ID# 4.2 TANK MANUFACTURER 431 TANK CO1:riGRIRATION: 1419 TAIv11K IS 434 <br /> ❑1.A STAND-ALONE r F- <br /> feL'O�.f�rsr�,� '2.ONE IN A COMPAR ENl'ED Wrt- <br /> -ePP <br /> Com mcowpageforimchcomiartmect is The unit. <br /> DATE UST SY TEM CISTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS N THE UNIT 437 <br /> Z rte-- 4g w c a <br /> III.TANK USE AND CONTENTS <br /> TANK USE In.MOTOR VEHICLE FUELING ❑ lb.NLkRINA FUELING ❑ Ic.A TION FUELING 439 <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(lacludes 6'sed Oil) ❑ 5.EMERGENCY GENERATOR FUEL ir1SC g25281.1(c)) <br /> ❑ 6.OTFIER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a <br /> CONTENTS PETROLEUM: ❑ M.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 <br /> W3.DIESEL ❑ 5.JET FUEL [1 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL E] 9.OTHER PETROLEUM (Specify): <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ ro.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUS eci ): 44ob <br /> M <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 <br /> 44 <br /> PRIMARY CONTAINMENT• 5a 1.STEEL ❑ 3.FIBERGLASS [j6.INTERNAL BLADDER 4 <br /> ❑ 7.STEEL+INTERNAL LIVING ❑ 95.UNKNOWN ❑ 99,OTHER (Specify): <br /> s44a <br /> SECONDARY CONTAINMENT ❑ 1.STEELFIBERGLASS [:16.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 <br /> ❑ 90.NONE �95.UNKNOWN ❑99.OTHER(SpeciM: 445a <br /> OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT )g 3.FILL TUBE SHUT-OFF VALVE 451 <br /> ❑ 4.TANK MEETS REQLI REMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑1.SINGLE-WALLED W.DOUBLE-WALLED [199.OTHER 460 <br /> SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR 42636(093)) 463 <br /> PRIMARY CON'IAJNMENT 0 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): UAs <br /> SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RlGiD PLASTIC 4640 <br /> ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): ` <br /> PIPINGrWE BINE CONTALYMENT SUMP TYPE Ur 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 <br /> VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT LW 1.STEEL ❑ 4.FIBERGLASS C310.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4644 <br /> 46441 <br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL Q 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464E <br /> 464fl <br /> VR PRIMARY CONTAINMENT ( 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) �4' <br /> VR SECONDARY CONTAINMENT D I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(SpecifO 464h <br /> 464h1 <br /> VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLEWALL ❑ 2.DOLIBLEWALL 90.NONE 4641. <br /> RISER PRIMARY CONTAINMENT D t.STEEL ❑ 4.FIBERGLASS ❑ 30.RIGID PLASTIC 40.NONE ❑ 99.0'fFIER(Specify) 664j <br /> 464'( <br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k <br /> 464kl <br /> FILL COMPONENTS INSTALLED J91.SPILL BUCKET -3.STRIKER PLATFJBOTTOM PROTECTOR W4.CONTAINMENT SUMP 451 a-c <br /> VIZ UNDER DISPENSER CONTAINMENT(UDQ <br /> CONSTRUCTION TYPE t.SINGLE WALL [12.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 46- <br /> CONSTRUCTION MATERLAL ❑ t.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify► a69nc <br /> c <br /> VIII. CORROSION PROTECTION <br /> 8. <br /> STEEL COMPONENT PROTECTION C] 2.SACRIFICIAL ANODES) F-14.IMPRESSED CURRENT ❑ 6.ISOLATION �- <br /> iX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST ystem is compatible with the hazardous substance stored and that the information provided herein is true,accurate, <br /> and in full compliance ith Iggal requirements. <br /> 470. <br /> APPLICANT SIGNATURE DATE / p <br /> 472. <br /> APPLICANT NAME{print) <br /> APPLICANT TITLE <br /> Rev.(1212007) <br /> UPCF UST-B-112 <br />