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ink AM R D R-a L-1 3 FIED PROGRAM CONSOLIDATED FOIMP UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (one form per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11,111,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: 430x. I DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) - - 1. BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3 S-r1 F_ L L I S BUSINESS SITE ADDRESS 103. CITY 104. II. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. Q� S ' ❑ 1.A STAND-ALONE TANK Complete one page for each 1 I F_ 2 X F 5 2.ONE INA COMPARTMENTED UNIT compartment in the unit. DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. UMBER OF COMPARTMENTS IN THE UNIT 437. '2 D 0 t 17- 6 0 0 1 1-)- III. TANK USE AND CONTENTS TANK USE g la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 432 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 ❑ 1b.PREMIUM UNLEADED 440. ]•3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 1 SEL Z 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. ................................................................ ...........................................................I..... ............................................................................................................_................................................................................................................................................................ PRIMARY CONTAINMENT ❑ 1.STEEL g 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444x. .................................................................................................................................. ................._............................................................................._...............I........................ .............................................. SECONDARY CONTAINMENT ❑ 1.STEEL FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE �95.UNKNOWN ❑99.OTHER(Specify): 445a. _..._..._....--.................................................................................................................................................................................................................._..._.__._.._.............................._......._............_....................... OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS RE UIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION E UIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 99.OTHER 460. -.....- -........................................................................ ................................................................... _.._..........----._........._.._. SYSTEM TYPE 1.PRESSURE 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR.§2636(a)(3)] 458_ _........... ........................ ........................ _._. ...... PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a. _......._.................................................................._................................-................._.....................................................................................................................................-.............._............................................. SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. ❑ 90.NONE ❑ 95.UNKNOWN 11 99.OTHER(Specify): 464c. ......................_.........._.................._...................-..........................._._..._....._.............._......_........_..................................... .....................................-................................. ........................................_....._.._._...-. PtPING/FURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 464d. VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILUPIPE PIPING CONSTRUCTION X 464e. VENT PRIMARY CONTAINMENT ❑ 1.STEEL 'tel 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464e1_ ....__...._................_...._._.._....---.......__.._-..._._.__...._......_._._................. 464f. VENT SECONDARY CONTAINMENT ❑ 1.STEEL 10 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464H. ..............................._.._........................_...................._........................._......_.........._..........._.._....__.._....._._......._......._................................................................................................................-._......._.._....._..._..........._._......._._....------..._.__...._.........................._.................... 4644. VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46441,_,.. VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464hl. ................................._................................._........................_....._.........--._...-.............-- --............................................................_...................................................................................................._............................._._....._......_.._..- ..._..._._....--..._.__......._....._.......................... VENT PIPING TRANSITION SUMP TYPE _� [:11.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 4641. _....__.._.._.....................................................................- --................._._.._..._._................._................. ....................---...._._........_.........................................................._............................................_..........__...-....--......................___._...._._......_......._............................................. ........................................... 4641. RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464j1..___. ............................................................................__............................__.................._............._.._..._._._.....-........._..........................._.................._....._.........--..._........................_............_........_..................._...................................._._.........--..........__..__...._...................._........ SER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS [:110.RIGID PLASTIC 3,! 90.NONE q.99 OT�TFA«�^ 464k. ��r 464k1. _ _......_.................._........._.__.............._............................................_......_...... .._..........._...._..................................................----..........-_...........-----........._....._....__..._........_................................................_._...._...__ ....--'----_._._...._....._...._.........._.... _......_-c...... ILI-COMPONENTS INSTALLED 1.SPILL BUCKET ❑ 3.STRIKER PLATE BOTTOM PROTECTOR 4.CONTAINMENT SUMP 451a-c. VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE1.SINGLE.WALL _ - ❑ 2.DOUBLE WALL 0 3:-NO DISPENSERS _ ❑ 90.NONE _ -469a. ._-....-----..._..._. ... . .............................................. .... _._ ._.. ..... _.. ..... 469b. CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) „u• 469x. VIII. CORROSION PROTECTION 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 pYv d herein is true, accurate and in ull compliance with legal requirements. 470. APPLICANT SIGNATURE DATE 3 l (7 •Z Z 10, APPLICANT NAME(print) J !� �� 471. APPLICANT TITLE Cj.) lJ t L 472' J UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org