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;.Vd x r >ut o -rank Infonutioli h1struction .., 1 (Fomwdy SWCB PeMWAWhcaftw Fbm 13 and UPCFFotm , , Comleta a fUST fraU admy UST a UST This form be Our W making chaftez.For aWb that are part TYPE OF ACTION•aad A n1,N, DL a T form.For a UST of ar m mwdmmmcho 430. OF a thooppoprieft. box to' <. is the data on the foam.) 430L DATE UST P Y CLOSED—sor I. —Fr ' �° te UST wm jaw the doe this on aiaLSwas if due is 430b. DATE UST _ FACn=MNUMBM—ThisW=isfor y 3. BUSINESS NAME—Faurthecomplubp 103. BUSINESS SrM ADDRESS—Enter the sum address of the h. *.nichaft bufft tttaoabr,if applicable This addRss aaanst be the Physical kecefim of t. the fac;iuy.Post offeoe box sae rax . 104. CITY—Emrdmcityoris the f �h 432. TANK ID# r this blank.no Local will the state number m aha �+ for do s 3 tank identificadne 433. T the of etooktie 434. TANK CONFI the " x • >n' if the tack is a tack or One is ae � compartmented tmrt A separaft UST 435. DATE UST SYSTEM UWALLED—Eater the date aha kecai i and does not `sl -obem m of tha UST sysDem. This is the data of tack system hmer.If this is fora now' 1 b 436. TANK CAPACITYING the - Far liar data fr the coagagunuar covered by this tank -": 437 NUMBEROFCOMPARTMENTS IN THE UNM.Iftho took is coupormank eager do 439. TANK USE— the type oftank a1 of in the noir 440 TANK —Check 439s. gym cbeciced"Ofte tYPa of rm the 440e. Ifchocked"Other s ,the anon mmof the m tipa{ep t " paOVded[I a,the lime aped in t]ffi faCaiity'S Ileaaadotm Maariala 440b. Ifyoia &Dcmmmnomeofsubstanciamths (Lm, 443. TYPE OF TANK— �box the in the Piavmtmyx 444. TANK Y CONI' — •• of If the tank ' is rax ' - the in aha (I a•,ine teak wall the r }}. 445. TANK SECONDARY CANT R AE the m of the . f ftm mound m the view povided(Qi•,ribed abom BDA. If as a - If the ' is (' check.- ' the 445a. Ifyon the"a ofoseendery coursfinum is the <r , 452 OVERFILL ON—Check the boxes)m )s ofmare + ' ' 458. TYPE— the type of boadjud requirements of 23 CCR aM( m m tale tank "Stele m-aefas to piping ' and only valve. as m m the )( ped amwith axe or T&la Coda of is le d, 460. PIPINGCONSTRUCTIO iftha pqft is sb9bvalled at - 464. Y — the s)and to construct doe (i. undagruand 464a. A"y 464b PIPING SECONDARY CONT checked'0111010'SPOCiff ft tYPa I — ms) ' ' raw to onew"ft pWg a)(ia,cres, be )puvidd rhFbc 4"Q Ifyant the type of a PIPINGffl=NE CONT ' i VENT YCONT — the a) sumA Check-Nwe"ifs comommom only.)S type of in ( )vert Pte& (Now ofthe tank 4"f-fl VENT SECONDARY CONT —Cho&the a)mod to ccomw the s)(a 8. R>r the vest ' ' Fr containment in thela:Addrese of the 0* Specify Other type of 464"IVR PRIMMY CONT — dm s) to aha (L&,' ) For wi - Spa*Offiatyponfcomaimem m �Twomy 1 VR SECONDARY CON(' — a m the a)(e g, !hr tha n For wall ' ' - Other s). type of m tlm _ 4641 VENT PIPING TTION SUMPTYPE— of �- 4"j-jl space rhers RSER Y CO — he a) (iei 'o , ) for all ( )(ie„ ' for ' or ' ofthe ) g typof at er 48k-kIRISERSECONDARY OT he ' (s)used to construct second"munament for the rim . ' Far ' - Spedfy typo of in the s PiPmB+ )pmvkw 451a-c FML COMPO INSI• — b dow tlntWU tmk and fa11 applicable)aro' (If, 469x. UDC CONSTRUCTION TYPE—Check the boa to describe the tXpe of&qamwf comerseem system(3)(i e.,dbl=szr onews r If the System has on 46%. UDC CONSTRUCTION MATERIAL—Check ft box m thanomeidu Wed m Iffill ass a but no UDC,shack-Nor-. 469,. Ifyoe the • m the m the UDC 448. STEM COMPONENT PROTECTION—All systems comain guare,ated componaft Chock theapprupfurtoboxes)to desm'be all -means electrical isoand Ex me fib am oteed •canudionew:system which What food cOuPoamM fixon the subsurflice evvuuomsq4 ad headerW1100argasbusbmgL APPLICANT SIGNATURE—The stme parson who ages rho UST Opargung Permit App• on _Fri&ry hftm&tm Fam ai that the aU ' is taus space 'This sign is the etre& aril that tlm UST is with the 470. DATE—Enter the data atm foam was sipo& 471. APPLICANT NAME—Print r type thaname ofthopersoudgrdegtheto= is 472 APPLICANT TITLE—Eager the tide ofthe peaaoa signing the form. UPCF UST-B-712 ,. Rev.(1 - __ --