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IED PROGRAM CONSOLIDATED FO 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,11,HE IV,and IX below) 430 ❑ 1.NEW PERMIT E 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: 43M I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) IN ESS NAME me as FACILITY Ng�A-Doin B As 3 ©rzr0�. � U �ES TE SS ' ), 103 PA ,3�o 104 N-0 rhII.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 39 VON01485 v5o 6g0 ❑ 1.ASTAND-ALONE TANK r n V ❑2.ONE M A COMPARTMENTED UNIT. Complete one these for each con,porment in the unit. DATE Ug SYSTEM;STALLED 435 TANK.CiAPf+CI O_I�S_ 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 II .TAN USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ In.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: ala.REGULAR UNLEADED Ic.MIDGRADE UNLEADED lb.PREMIUM UNLEADED 440 i�1"3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 44oa NON-PETROLEUM'.❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ T SMGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ I.STEEL $Si.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444. SECONDARY CONTAINMENT ❑ 1.STEEL W.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE Cl 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION ❑ 1.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 5K.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[v CCR§2636(.HB)] asa PRIMARY CONTAINMENT ❑ L STEEL W 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ I.STEEL R 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 46,11, ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SOME TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 46,10 VENT SECONDARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4Mf 464n VR PRIMARY CONTAINMENT PELSTEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4644 464 1 VR SECONDARY CONTAINMENT 911.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ L SINGLE W L 2.DOUBLE WALL EI 90.NONE 46,i RISER PRIMARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE El99.OTHER(Specify) 4641 464 1 RISER SECONDARY CONTAINMENT ❑ I.STEEL .FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641, 464kl FILL COMPONENTS INSTALLED ❑ L SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL OL4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 449. IX AP ICANT SIGNATURE CERTIFICATION: I certify that UST s is compatible hazardous substance stored and that the information provided herein is true,accurate, and in f om li ce i legal requye C-- APPLICANT SIGNATU 001F DATE ^ q ala APPLICANT ,. , ^ / 1. APPLICANT TITLE 472' UPCF UST-111-1/2 ��'Y�J Rev.(122007)