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a • ; UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK K,Q OPERATING PERMIT APPLICATION -TANK INFORMATION (one formper UST) Ufl TYP 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) 1430 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: 430' DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) _ _ I B SINESS NAME (Same as FACILITY NAME or DIA -Doing Business As) 3 B SINESS SITE ADDRESS I03 crrY 1);.Z Si? jam` Nj II. TANK DESCRIPTION TANK ID # /% / 432 v �! TANK MANUFACTURER 433 4 TANK CONFIGURATION: THIS TANK IS IT5 L - � C> ) Z ci C/L u1 n J� � ", 11 ❑ I . AND -ALONE TANK .ONE IN A COMPARTMENTED UNIT. 1 lfJ 1 I Complete oro pW for each cmnparwymn M the Urk DATE US SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF MPARTMENTS IN THE UNCI 437 III TANK USE AND CONTENTS TANK USE ❑ la. MOTOR VEHICLE FUELING ❑ !b. MARINA FUELING ❑ Ic. AVIATION FUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (ln jW. Used o 1) ❑ 5. EMERGENCY GENERATOR FUEL [HSC §25281.5(c)] ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ". OTHER (Specify): 439. CONTENTS PETROLEUM: ❑ la. REGULAR UNLEADED ❑ lc. MIDGRADE UNLEADED ❑ lb. PREMIUM UNLEADED 440 ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8.pETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM $ 4401 NON -PETROLEUM: USED OIL ❑ 10. ETHANOL 5<1. OTHER NON-PETROLEUM(Specify): . 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL . DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT 1. STF,EL ❑ 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 ❑ 7 EL+ INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 444. SECONDARY CONTAINMENT L STEEL ❑ 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify) 445a OVERFILL PREVENTION 1. UDBLE & VISUAL ALARMS 2. BALL FLOAT ❑ 3. FILL TUBE SHUT-OFF VALVE 452. 1:14. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT! WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION SINGLE -WALLED ❑ 2. DOUBLE -WALLED [199. OTHER 460 SYSTEM TYPE . P SSURE ❑ 2. GRAVITY [13. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR §2636(ax3) 458 PRIMARY CONTAINMENT . 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 464b ❑ 90. NONE ❑ 95. UNKNOWN (] 99. OTHER (Specify): _�y,c': ,e -4, r / - 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE 4644 VI. VENT, VAPOR COVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1. STEEL 4. FIBERGLASS 10. RIGID PLASTIC 0 90. NONE ❑ 99. OTHER (Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ I. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGIDPLASTIC ❑ 90. NONE 99. OTHER (Specify) 464E 464[1 VR PRIMARY CONTAINMENT L STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE 99. OTHER (Specify) 4648 464 l VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE 99. OTHER (Specify) 464h 4647,1 VENT PIPING TRANSITION SUMP TYPE 1. SINGLE WALL 2. DOUBLE WALL 90. NONE 464 RISER PRIMARY CONTAINMENT 1. STEEL 4. FIBERGLASS ❑ I0. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464j 464' I RISER SECONDARY CONTAINMENT L STEEL 0 4. FIBERGLASS U 10. RIGID PLASTIC 0 90. NONE 99. OTHER (Specify) 464k 464k 1 I FILL COMPONENTS INSTALLED ❑ 1. SPILL BUCKET ❑ LK 3. STALKER PLATE(BOTTOM PROTECTOR 4. CONTAINMENT SUMP 4SIa VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ❑ 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS G4761NE 469. CONSTRUCTION MATERIAL ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 469be VIII_ CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT. ISOL.ATiON 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 is full fiance with legal requirements. APPLICANT SIGNATURE DATE 470. APPLICANT NAME (print) > 471 APPLICANT TITLE 4r_ A kra i c ti 4 11 ,: �- (, UPCF UST -B- 1/2 Rev. (1212007) v