BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

0 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK I, p OPERATING PERMIT APPLICATION - TANK INFORMATION (One form per UST) !� p TYP ACTION (Check one item only. For an UST permanent closure or removal, complete only this section and Sections[, It, III, IV, and --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: 430aI DATE EXISTING UST DISCOVERED: 430b L FACILITYvNFORMATION FACILITY ID # (Agency Use Only) 1 B SINESS NAME (Same as FACILITY NAME or DBA Doing Business As) 3 �- C'S C TL A -S K //Cl BFISPIESS SITE ADDRESS Im CITY C. t II. TANKDESCREMON TANK ID # �.j��/,, 432 TANK MANUFACTURER 433 TANr coNFIGuRATION: THm TAmK is 434 J s /�^ ❑ 1. AND-A[.oNE TANK 4 PICG It1 -ONE INA COMPARTMENTED UNIT. CJ P •� G de one nor orb in the urk DATE UST SYSTEKINSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 - IIL'TANK-DSE-ANo Comm: TANK USE ❑ la. MOTOR VELBCLE FUELING ❑ Ib. MARINA FUELING ❑ lc. AVIATION FUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (tododr. Used Oil) ❑ 5.YkMERGENCY GENERATOR FUEL [HSC §25281.5(c)l ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la. REGULAR UNLEADED ❑ la MIDGRADE UNLEADED ❑ lb. PREMIUM UNLEADED 440 ❑ 3. DIESEL ❑ 5. IET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9.0THER PETROLEUM (specify): 440a NON -PETROLEUM 7.jJSED OIL El 10. 1.OTHER NON -PETROLEUMS ): Ol L 440b 1 :'TANKCONSTRUCTION., TYPE OF TANK ❑ 1,5INGLE WALL nY2 DOUBLE WALL 0 95. UNKNOWN 443 PRIMARY CONTAINMENT . STEEL 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 ❑ 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (S ): 444a SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445 ❑ 90. NONE ❑ 95. UNKNOWN Q 99. OTHER (Specify)6 j .c . c L e v 445a OVERFILL PREVENTIONL BLE & VISUAL ALARMS 2. BALL FLOAT 3. FILL TUBE SHUT-OFF V VE 452 C. T AUDNK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT! WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION_U71-SINGLE-WALLED ❑ 2. DOUBLE -WALLED ❑ 99.OTHER 460 SYSTEM TYPE URE ❑ 2. GRAVITY 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR §2636(x)(3)] 458 PRIMARY CONTAINMENT U4.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 0 10. RIGID PLASTIC 460 ❑ 90. NONE ❑ 95. UNKNOWN Q 99. OTHER (Specify):c , f 464c PIPING/TURBtNE CONTAINMENT SUMP TYPE ❑ 1. SINGLE WALL 2_ DOUBLE WALL 90. NONE 4M4d VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILU PIPE PIPING CONSTRUCTION. VENT PRIMARY CONTAINMENT I. STEEL 0 4. FIBERGLASS 0 l0. RIGID PLASTIC 90. NONE ".OTHER (Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS 10. RIGID PLASTIC Ej 90. NONE -U-99. 6FHER (Specify) 464f 464ft VR PRIMARY CONTAINMENT 0 1. STEEL ❑ 4. FIBERGLASS 10. RIGID PLASTIC ❑ 90. NONE 99. OTHER (Specify) 464g 464gl VR SECONDARY CONTAINMENT ❑ 1. STEEL C3 4. FIBERGLASS 0 10. RIGID PLASTIC 90. NONE 99. OTHER (Specify) 4646 464h1 VENT PIPING TRANSITION SUMP TYPE 1. SINGLE WALL 2. DOUBLE WALL 90. NONE 464L RISER PRIMARY CONTAINMENT El1. STEEL 4. FIBERGLASS Ll10. RIGID PLASTIC 90. NONE 0 99. OTHER (Specify) 464j 464'1 RISER SECONDARY CONTAINMENT 0 1. STEEL 0 4. FIBERGLASS 0 10. RIGID PLASTIC 0 90. NONE E3 99. OTHER (Specify) 464k 464-1 FILL COMPONENTS INSTALLED ❑ 1. SPILL BUCKET 0 3. STRIKER PLATFIBOTTOM PROTECTOR 0 4. CONTAINMENT SUMP 451x VII. UNDER DISPENSER CONTA gN%M.(UDCj. CONSTRUCTION TYPE ❑ 1. SINGLE WALL ❑ 2 DOUBLE WALL ❑ 3. NO DISPENSERS W90. NONE 469a CONSTRUCTION MATERIAL E3 1. STEEL 0 4. FIBERGLASS 10. RIGID PLASTIC Ll 99. OTHER (Specify) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2 SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT 6. ISOLATION 448. UL 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 compliance with legal requirements. APPLICANT SIGNATURE DATE 470. of i APPLICANT NAME (print) 071. APPLICANTTILi.E 471_ UPCF UST -B - 1/2 Rev. (12/2007)