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NIFIED PROGRAM CONSOLIDATED F61% 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 1,11,III,IV,and IX below) 430 ❑ L 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: 430aDATE EXISTING UST DISCOVERED: 430b* .t FACILITY ID#(Agency Use Only) �t BUSINESS NAME(Same as FACILITY NAME or DBA-Doin Business As) 3 '� e 14 0_ (o t BUSINESS SITE ADDRESS 107 CITY 104 n� fen 77777- TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 Tank #6 Xerxes ®I.A STAND-ALONE TANK ❑ 2.ONE IN A COMPARTMENTED UNIT. Complete one Page for each compartinem in the unit. DATE UST SYSTEM INSTALLED 433 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 1N THE UNIT 437 4 d TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ le.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)I ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ® 99.OTHER (Specify): B100 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S . 440s NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 11.OTHER MON-PETROLEUMS i . B11}00 440b N_11<ss' ° �y ;�<. _ tl Y s.' .ra ., _. -.. ..:-.. TYPE OF TANK 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ I.STEEL W 3.FIBERGLASS 6.INTERNAL BLADDER 444 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT L STEEL 913.FIBERGLASS 6.EXTERIOR MEMBRANE LINER 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER S i : 445a OVERFILL PREVENTION EI 1.AUDIBLE&VISUAL ALARMS 0 2.BALL FLOAT W 3,FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS RE UIREMENTS FOR EXEMPTION FROM OVERFILL�gPREVENTION EQUIPMENT PIPING CONSTRUCTION 1.SINGLE-WALLED ®2.DOUBLE-WALLED ❑99.OTHER460 SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR§263 aX3) 458 PRIMARY CONTAINMENT 1.STEEL KI 4.FIBERGLASS Ej S.FLEXIBLE 0 10.RIGID PLASTIC 464 ❑ ".NONE ❑ 95.UNKNOWN ❑ 99.OTHER(S i ): 464a SECONDARY CONTAINMENT 0 1.STEEL 114.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ ".NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specifyk 464c PIPING/TURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL 2.DOUBLE WAL{aL.��■�y{ya/.�� 90.NONE yy [ 464d .,,.> ar,. s.: ,-.w....n.< ... .:, ....s. .r. s xa...». .r. ,.v,,. a..:. <s -..v.•. VENT PRIMARY CONTAINMENT I.STEEL 91 4.FIBERGLASS El 10.RIGID PLASTIC Lj 90.NONE 0 99.OTHER(Specify) 464e 46401 VENT SECONDARY CONTAINMENT t.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 0 90,NONE t3 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10,RIGID PLASTIC M 90.NONE 99.OTHER(Specify) 4645 VR SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10,RIGID PLASTIC M 90.NONE 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE I.SINGLE WALL 2.DOUBLE WALL 9o.NONE 4641, RISER PRIMARY CONTAINMENT IN L STEEL U 4.FIBERGLASS U 10.RIGID PLASTIC U 90.NONE 99.OTHER(Specify) 4 464i 1 RISER SECONDARY CONTAINMENT L STEEL 91 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET ■g 3.STRIKER PLATE/BOTTOM PROTECTOR 13 4.CONTAINMENT SUMP 451a< 3t Kfi y�j ka7 4 <W K �r CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469i CONSTRUCTION MATERIAL ❑ L STEEL 0 4.FIBERGLASS ❑ 10.RIGID DPPLASTIC g ❑ 99.OTHER S i 469b-c STEEL COMPONENTN � < PROTECTION ❑ 2.SACRIF[CIAt.ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448 CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full compliance w' i al rectuirements. APPLICANT SIGNATURE _ DATE azo. APPLICANT NAME(print) 71 APPLICANT TITLE �, 472. UPCF UST-B-1/2 Rev.(12/2007)