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UNIFIED PROGRAM CONSOLIDATED FORM fj U UNDERGROUND STORAGE TANK 4(^1 OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. FoST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 430 ❑ 1.NEW PERMIT RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as F ILITY NAME or DBD g vinesss s) S r 3 41') i H fYl (V c F- BUSINESSSITEADDRESS 103 1 CITY IL, S`�-OC ,��1 C A 104 0.H a IL TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 V S C ^ ❑1.A STAND-ALONE TANK (� v �C! G;a.I VE INA COMPARTMENTED UNIT. Complete one page for each in the mdt DATE UST SYSTEM INSTALLED 435 TANK CQPAC_ 11 Y1N GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 M.TANK USE AND CONTENTS TANK USE a.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(hdudes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHERS OTHER(Specify): 43% CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED Q-4b.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. INGLE WALL OUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT W.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑99.OTHER (SM: S 444a SECONDARY CONTAINMENT ❑ 1.STEEL ERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify) 445a OVERFILL PREVENTION 1.AUDIBLE 8c VISUAL ALARMS 2.BALL FLOAT FILL TUBE SHUT-OFF VALVE 452. ❑4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT Ve PRODUC WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1. INGLE-WALLED 2.DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE RESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL ❑4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE .SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVER )AND RISER L FILL:PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT0 1.STEEL Ur4.FIBERGLASS 13 10.RIGIDPLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC NONE ❑ 99.OTHER(Specify) 464f VR PRIMARY CONTAINMENT ❑ 1.STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC 464fI 90.NONE ❑ 99.OTHER(Specify) 4648 VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING Y CON A SUMP TYPE ❑ I. GLE WALL 2.DOUBLE WALL 90.NONE 464i. RISER PRIMARY CONTAINMENT STEEL ❑ 4.FIBERGLASS U 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT 0 1.STEEL in 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED IFI14SPILL BUCKET 3.STRIKER PLATEIBOTTOM PROTECTOR 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 5YI.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469. CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS 010.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in co 4k lestal requirements. APPLICANT SIGNATURE DATE j*TAJ 470. APPLICANT NAME(print' A Lr-A �� q �p� L10471. APPLICANT TITLE � 472. T�t V UPCF UST-B-1/2 Rev.(12/2007)