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( S j� � J UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (one form per UST) I.YPEOFACTION (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 ❑ 66 TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: t,' i{ 430b I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) BUSIN S NAME Same as FACILITY NAME or DBA-Doing Business As) 3 BUSINESS SITE ADDREBS I 7E 4arryLa 103 CITY 104 II, TANK DESCRIPTION TANK ID # 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 X //�� A STAND-ALONE TANK G 2. ONE IN A COMPARTMENTED UNIT . Complete one page for each compartment in the unit. DATE ST SY T'M )TALLED 435 TANK�O CIS OGALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 :L f III. TANK USE AND CONTENTS TANK USE la. MOTOR VEHICLE FUELING ❑ 16. 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 ❑ 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 ❑ L SINGLE WALL 2. DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1 . STEEL Wo FIBERGLASS ❑ 6. INTERNAL BLADDER 444 ❑ 7. STEEL + INTERNAL LINING Cl 95. UNKNOWN ❑ 990 OTHER SECONDARY CONTAINMENT ❑ 1 . STEEL 3. FIBERGLASS (Specify): 444a ❑ 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 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 SUCTION [23 CCR §2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ 1 . STEEL [14. 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 PIPINGITURBINE CONTAINMENT SUMP TYPE ❑ 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE 4644 VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I . STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464f 464n VR PRIMARY CONTAINMENT ❑ 1 . STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 4648 464 1 VR SECONDARY CONTAINMENT ❑ I . STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464h VENT PIPING TRANSITION SUMP TYPE ❑ I. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE 464hl464i. RISER PRIMARY CONTAINMENT ❑ L STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464j 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 ❑ 3 . STRIKER PLATEIBOTTOM PROTECTOR ❑ 4. CONTAINMENT SUMP 45la-c VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ❑ 1 . SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3 . NO DISPENSERS ❑ 90. NONE 469a CONSTRUCTION MATERIAL ❑ 1 . STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99, OTHER (Specify) 469b-c VIIL CORROSION PROTEC'T'ION STEEL COMPONENT PROTECTION. ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED ' CURRENT ❑ 6. ISOLATION 448. Me APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate, and in full PAMI e uirements. APPLICANT SIGNATURE DATE 470. APPLICANT NAME (print) 471' APPLICANT TITLE 472. UPCF UST-B - 1/2 Rev. (12/2007)