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UNIFIED PROGRAM CONSOLIDATED FORI( 1 ) UNDERGROUND STORAGE TANK (� 12up OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per usT) TYPE OF ACTION (Check one item only. For UST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 430 ❑ 1.NEW PERMIT W3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a 1 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID# 4 'yyUUse nl)� 77 BUSINESS N (Same as CIL NAME DBA-Doin Business As) 3 Gt U c. �,. Q/ J1 BUSINESS SITE AD SS X 13 CITY / !oa (0- nL n e-l 2--o(z> H.TANK DESCRIPTI N TANK ID# 432 TANK MANUFACTURER 433 TAW CONFIGURATION: THIS TANK IS 434 /, ASTAND-ALONE TANK �V� 5 q ><e- S ❑2.ONE IN A COMPARTMENTED UNIT. Complete one page for each cowywWMft in the wit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 Z vo© III.TANK USE AND CONTENTS TANK USE irla.MOTOR VEHICLE FUELING ❑ ]b.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(01 ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ ]c.MIDGRADE UNLEADED ❑ 1b.PREMIUM UNLEADED 440 0:�.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ l 1.OTHER NON-PETROLEUM(Specify): 440b IV. ':TANK CONSTRUCTION_ TYPE OF TANK ❑ 1.SINGLE WALL JW2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL OKI.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL WING ❑95.UNKNOWN ❑ 99.OTHER (S 444a SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NOW tj 95.UNKNOWN ❑99.OTHER(S }: 445a OVERFILL PREVENTION 11 1.AUDIBLE&VISUAL ALARMS 0 2.BALL FLOAT FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PROpU T/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED 24.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑2 GRAVITY 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ L STEEL Cr,4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 5.UNKNOWN ❑99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 5.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER Y FILL.PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS 13 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0.NONE ❑ 99.OTHER(Specify) 4641£ 464£1 VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC EJ 90.NONE 99.OTHER(Specify) 464g 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC .NONE ❑ 99.OTHER(Specify) 464h VENT PIPING TRANSITION SUMP TYPE 1.SINGLE 464hl WALL ❑2.DOUBLE WALL NONE 4641. RISER PRIMARY CONTAINMENT L STEEL 4.FIBERGLASS EJ 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 464j RISER SECONDARY CONTAINMENT STEEL D 4.FIBERGLASS0 10.RIGID PLASTIC 90.NONE 464'1 P. 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED .SPILL BUCKET STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT£UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL .FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES) ❑4.INIPRESSED CURRENT ❑ 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 com li a with lenal requirements. APPLICANT SICyNAIURE - DATE2 470. APPLICANT NAME(print)�._ 471' APPLICANT ,J �� 472• i t ® ' r� V` LI UPCF UST-B-1/2 Rev.(12/2007)