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UNIFIED PROGRAM CONSOLIDATED FORM 0 0 g 4�95 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 I, II, III, IV, and IX belovy) ,� 4� l F1 NEW PERMIT C1 3 , RENEWAL PERMIT [15. CHANGE OF INFORMATION 7 1 ❑ 6. TEMPORARY UST CLOSURE [j 7. UST PERMANENT CLOSURE ON SITE BL8, UST REMOVAL DATE UST PERMANENTLY CLOSED: awx6cwj 430a DATE EXISTING T DISCOVERED: " 430b I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) _ _ 1 BUSINESS NAME (Same as F CILITY NAME or DBA-Doing Business As) 3 BUSINESS SITE ADDRESS l03 CITY 104 1 IL TANK DESCRIPTION TANK ID # �� 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 1 . A STAND-ALONE TANK ❑ 2. ONE IN A COMPARTMENTED UNIT . _ Complete one Me for each com ent in the unit DATE UST SYSTEM INSTALLED 435 TANK CAPACITY GALLONS 436 NUMBER OF CO TMENTS IN THE UNIT 437 M. TANK USE AND CONTENTS TANK USE ❑ la. MOTOR VEHICLE FUELING ❑ lb. MARINA FUELING ❑ Ic. 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: ❑ 1 a. REGULAR UNLEADED ❑ lc. MIDGRADE UNLEADED ❑ lb. PREMIUM UNLEADED 440 (Z3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9, OTHER PETROLEUM (specify): CO Ai X G 440a NON-PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ❑ it . OTHERNON-PETROLEUM (Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK aK 1 , SINGLE WALL ❑ 2. DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT JX 1. STEEL ❑ 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 ❑ 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1 . STEEL [13, FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445 90. NONE ❑ 95. UNKNOWN [199, OTHER (Specify): 445a OVERFILL PREVENTION El1. 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 [12. DOUBLE-WALLED ❑ 99, OTHER 460 SYSTEM TYPE ❑ 1 . PRESSURE ❑ 2. GRAVITY . CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR §2636(a)(3)] 458 PRIMARY CONTAINMENT ,f�=1. STEEL ❑ 4. 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 4646 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464c PIPINGITURBINE CONTAINMENT SUMP TYPE ❑ 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE 464d VI, VENT, VAPOR_ RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAHdMENT CjEri . STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ 1 . STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC 40 $40. NONE ❑ 99. OTHER (Specify) 46UP 464f1 VR PRIMARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC 0. NONE ❑ 99, OTHER (Specify) 4648 464 1 VR SECONDARY CONTAINMENT ❑ 1 . STEEL ❑ 4. FIBERGLASS ❑ 10. RIGIDPLASTIC . NONE ❑ 99, OTHER (Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ 1 . SINGLE WALL ❑ 2. DOUBLE WALL NONE 464i, RISERPRIMARY CONTAINMENT . STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 4641 4641 RISER SECONDARY CONTAINMENT ❑ 1 . STEEL ❑ 4. FIBERGLASS ❑ 10. RIGIDPLASTIC . NONE ❑ 99. OTHER (Specify) 464k 464k1 FILL COMPONENTS INSTALLED ❑ 1 . SPILL BUCKET ❑ 3. STRIKER PLATE/BOTTOM PROTECTOR ❑ 4. CONTAINMENT SUMP XVI;' 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 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 cjMpliance with le al requirements. APPLICANT SIGNATURE >Z DATE azo. APPLICANT NAME (print) S'� q )471 APPLICANT TITLE 472. UPCF UST-B - 1/2 Rev. (12/2007)