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aIE 2sft) -- I-, UNIFIEDUNDERGROUND CONSOLIDATED STORAG TANK ORM (/ (�1 1 Its c� v OPERATING PERMIT APPLICATION-TANK INFORMATION(One£orm 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) 10 b «a I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) .- 3 BUSINES IQTEADDRFrSS, liY �r 103 1 CITYOIJ G 10 II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 ��TA��LL[[CC CONFIGURATION: THIS TANK IS 434 - I 1 1, A STAND-ALONE TANK 7 X r X \ ❑2.ONE INA COMPARTMENTED UNIT. "7q (/ // JJJ Complete one page for each compartment in the unit. DATE US SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPART NTS IN THE UNIT 437 C II .TANK iTSE=AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.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.OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIA ION GAS ,,`` [18.PETROLEUM BLEND FUEL 9.OTHER PETROLEUM (Specify): Q e /V O 44oa NON-PETROLEUM:❑ 7.USED OIL 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTIONt"11" TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL OC3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE R 95.UNKNOWN [199.OTHER(Specify): 445a OVERFILL PREVENTION ❑ 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 .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 ❑ 1.STEEL4.FIBERGLASS El S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECditkfw�AND SER 1 FILL PIPE PIPING CO _STIiUCTI(}N VENT PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 464171 VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC0.NONE ❑ 99.OTHER(Specify) 4648 464 I VR SECONDARY CONTAINMENT ❑ 1.STEEL Sb4.FIBERGLASS ❑ 10.RIGID PLASTIC NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 4641. RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS U 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 464'1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET W.STRIKER PLATE/BOTTOM PROTECTOR EX4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTINMEN`I"(TJDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL IM.DOUBLE WALL ❑ 3.NO DISPENSERS XL90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS 10-RIGID PLASTIC ❑ 99.OTHER(Specify) 469b-c VIII. CORROSION,PROTECTIONn STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED 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 truejr.acctgte, and in full compliance with legal requirements. APPLICANT SIGNATURE DATE F. ,a azo. APPLICANT NAME(print) 471. APPLICANT TITLE 472 f :i UPCF UST-B-1/2 Rev.(12/2007)