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UNIFIED PROGRAM CONSOLIDATED FORM s UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 430 ❑ 1.NEW PERMIT 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4301 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) I ol M BUSINESS NAE(Same as FACILITY NAME or DBA-Doing Business As) 3 W a BUSINESS SITE ADDRESS l03 C['Y 104 c H.TANK DESCRIPTION TANK ID#-T A0 50`1 p,( 432 TANK MANUFACTURER 433 TA CONFIGURATION:THIS TANK IS 434 rl 7 A STAND-ALONE TANK 12 ONE IN A COMPARTMENTED UNIT. ete one page for each c=pamnera in the unit DATI UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 8 o coo IIL TANK USE AND CONTENTS TANK USE 19 la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ tc.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 ❑ 95.UNKNOWN ❑ 99.OTHERS OTHER(Specify): 439a CONTENTS PETROLEUM: ,(� la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND 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 2.DOUBLE WALL ❑95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL OU 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑95.UNKNOWN ❑ 99.OTHER (S c' ): 444a SECONDARY CONTAINMENT ❑ I.STEEL 3.FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE 13 95.UNKNOWN ❑99.OTHER(Specify445a OVERFILL PREVENTION X 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 ❑1.SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑3.CONVENTIONAL SUCTION ❑ 4.SAFE [23 CCR§2636(.)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL J9 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL RJ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FML PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 L STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC „(q 90.NONE ❑ 99.OTHER(Specify) 464f 464fl VR PRIMARY CONTAINMENT ❑ 1.STEEL IQ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464g 464 I VR SECONDARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT A 7.S 4.FIBERGLASS U 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464j RISER SECONDARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS 464'1 l0.RIGID PLASTIC J 90.NONE 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLEDJ9 1.SPILL BUCKET 3.STRIKER PLATEwTTOM PROTECTOR j0 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT.(UDC) CONSTRUCTION TYPE 1.SINGLE WALL [12.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑4.IMPRESSED CURRENT ❑ 6.ISOLATION 448• IX. APPLICANT SIGNATURE CERTIFICATION:I certify that tgh UST lystjo is compatible with the hazardous substance stored and that the information provided herein Is true,accurate, and in full Jowniii..withlegal re uirements. APPLICANT SIGNATURE DATE 470• APPLICANT NAME(print) 471. APPLICANT TITLE 472. 149-in cht Qwne, UPCF UST-B-1/2 4 ' Rev.(12rM7)