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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) P F 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: 430a DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 BU ESS SITE AE DRESS l03 CITY loa ~' L� Ft U.TANK DESCRIPTION TANK m# 432 TANK MANUFACTURER 433 TANK RATION: THIS TANK IS 434 ASTAND-ALONE TANK Q O ❑2.ONE IN A COMPARTMENTED UNIT. C-Ticte one page for each c=qarWwW m the mt DATE UST SYSTEM INSTALLED 435 TANK CAPAC[I'Y IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 III.TANK USE-AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ Ic.A TION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(htdude Used Oil ❑ 5.fihfERGENCY GENERATOR FUEL[HSC§Z5281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN Lk99.OTHER(Specify): 439. CONTENTS PETROLEUM: ❑ l a.REGULAR UNLEADED ❑ l c.MIDGRADE UNLEADED ❑ I b.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETP.OLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM $ 440a NON-PETROLEUM:❑ Z ED OIL ❑ 10.ETHANOL L OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION TYPE OF TANK 011.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER El 7.STEEL+INTERNAL LINING [395.UNKNOWN OTHER (S ): tt ;I C. 444a SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.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 .FILL TUBE SHUT-OFF VALVE 451 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT.!WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 1.SINGLE-WALLED LE-WALLED ❑99,OTHER 46D SYSTEM TYPE ❑ t SSURE GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(ax3)] 458 PRIMARY CONTAINMENT 11 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 ❑ 99.OTHER(Specify): 464c PIPINGITURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL.PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT C1 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT 1.STEEL U 4.FIBERGLASS 10.RIGID PLASTIC C3 90.NONE 99.OTHER(Specify) 464f 4mn VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464g 464 1 VR SECONDARY CONTAINMENT ❑ I.STEEL U 4.FIBERGLASS ❑ I0.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464h VENT PIPING TRANSITION SUMP TYPE 464h1 1.SINGLE WALL 2_DOUBLE WALL 90.NONE 464L RISER PRIMARY CONTAINMENT ❑ L STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 464j 464'I RISER SECONDARY CONTAINMENT 0 L STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 4644 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATEJBOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 451a-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 46% CONSTRUCTION MATERIAL ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696-c 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 provided herein is true,accurate, and in full com [lance with legal requirements. APPLICANT SIGNATURE ) DATE 470- - 1 L . Zr i s✓�> APPLICANT NAME(print) an APPLICANT TITLE 471_. UPCF UST-B-1/2 Rev.(12/2007)