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AV UNIFIED PROGRAM CONSOLIDATED FORM MAR 10 2 116 UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(ptte�e >J 1*6. OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,III, ,-end .1 7Tl(!rlsl�o NEW PERMIT 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION TEMPORARY UST CLOSURE ] 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: (//rJ/G 1iC�� 430a DATE EXISTING UST DISCOVERED: 430b I. FACILITYINFORIVIATION FACILITY ID#(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAME or DBA-D ng Busine�j`As) 3 BUSINESS SITE ADDRESS 03 ITy D / 04 IL TANK DESCRIPTION_ TANK ID# +--� ) )l�,s£/ 432 TANK MANUFACTURER 433 TA CONFIGURATION: THIS TANK IS 434 b� t� C- STAND-ALONE TANK ❑2.ONE IN A COMPARTMENTED UNIT. Complete one page for each compartment in the unit. DATE UST SYS EM IN TALLER 435 TANK CAPACITY IN G NS 436 NUMBER OF PARTMENTS IN THE UNIT 437 III.TANK USE AND CONTENTS TANK USE MOTOR VEHICLE FUELING ❑ Ib.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 GENER OR FUEL ❑ 95.UNKNOWN ❑ 99.OTHERS eci 439a ( P 1'Y) CONTENTS PETROLEUM: a.REGULAR UNLEADED ❑ Ic.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 SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT jj!!�,STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ I.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 0.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION 1.AUDIBLE k VISUAL ALARMS Ej 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 INGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY 20T.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR§2636(a)(3)) 458 PRIMARY CONTAINMENT )2"1,STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ .STEEL. ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b .NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 0.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT L STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTICa9.NONE ❑ 99.OTHER(Specify) 4641' 464n VR PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC NONE ❑ 99.OTHER(Specify) 4646 464 I VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC er 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 0.NONE 464i. RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT El 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 1,P-0.NONE ❑ 99.OTHER(Specify) 464k 4641,1 FILL COMPONENTS INSTALLED ❑ 1.SPILL.BUCKET E3 3.STRIKER PLATE/BOTTOM 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 VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRJFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION ClI 448 II. 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 liance with legal requirements. APPLICANT SIGNATURE DATE /b / 470, APPLICANT NAME(print) ( �� 471 APPLICANT TITLE 472 UPCF UST-B-112 Rev.(12/2007)