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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION(Oneform per usT) TYPE OF ACTION (Check one item only. For an UST permment closure or removal,complete only this section and Sections 1,It III,IV,and IX below) 430 ❑ t.NEW PER ❑ 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION El 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 010i DATE EXISTING UST DISCOVERED: 43 1. FACII TI Y INFORMATION FACILITY ID#(Agency Use Outy) 1 BUSINESS NAME{jame m FACILITY Noor BA•Doiog Business;As) / 3 \ k BUSINESS SITE ADD SS 1m CITY .r IM If.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 -rA/� /� �/r /(� ❑l 1.A STAND-ALONE TANK oS 5- i 0 J f <��i� I yl 2.�O MACAO�ARTMENTEm We DATE UST SYSTEM INSTALLED am TANK CAPAPT IN GALLONS 436 NUMBER OF MPARTMENTS IN THE UNIT 437 III.TANK USE AND CONTENTS TANK USE a Ia.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING [3Ic.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(6 &s Uw8 att ❑ 5.EMERGENCY GENERATOR FUEL[HSC§252815(.)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADEDb.PREMIUM UNLEADED 440 ❑ 3.DIESEL [15.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 410. NON-PETROLEUM:❑ 7.USED OIL ❑ 111.ETHANOL El 11.OTHER NON-PETROLEUMS 440b IV. TANKCONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL .DOUBLE WALL Q 95.UNKNOWN 443 PRIMARY CONTAINMENT STEEL [13.FIBERGLASS Ll 6.INTERNAL BLADDER 444 7.STEEL.INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER S 441. SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE [195.UNKNOWN .OTHER(S ): t! 445. OVERFILL PREVENTION ON.AUDIBLE&VISUAL ALARMS .B L FLOAT .FILL TUBE SHUT-OFF VALVE 452 4.TANK MEETS REQUEMENTS F) I4EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑I.SINGLE-WALLED .DOUBLE-WALLED ❑_99.OTHER 460 SYSTEM TYPE 1.PRESSURE LJ .GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑4.SAFE SUCTION[23 CCR§2636(.X3) 458 ❑ PRIMARY CONTAINMENT 1.STEEL4.FIBERGLASS .FLEXIBLE ❑ 10.RIGID PLASTIC 461 ❑ 90.NONE ❑ 95.UNKNOWN 0 99.OTHER(Spaciy): 461. SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN 99.OTHER(Speedy): 464c PIPING1111"INE CONTAINMENT SUMP TYPE .SINGLE WALL 02.DOUBLE WALL [3 90.NONE 46Md VI.VENT,VAPOR RECOVERY(VR)AND RISER I FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT I.STEEL a 4.FIBERGLASS 0 10.RIGIDPLASTIC 0 90.NONE MOTHER(Specify) 464e VENT SECONDARY CONTAINMENT ❑ I.STEELE`_ FIBERGLASSEl 10.RIGID PLASTIC 0 90.NONE ".OTHER(Specify) 46af VR PRIMARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS 0 I0.RIGIDPLASTIC ❑ 90.NONE99.OTHER S 4648 ( P¢iTY) 4648 461 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.R1GIB PLASTIC 90.NONE 99.OTHER(Specify) 461h 46MI VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALLQ 2.DOUBLE WALL 90.NONE 464i RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGB7 PLASTIC 90.NONE 99.OTHER(Specify) 46aj 464'1 RISER SECONDARY CONTAINMENTEl L STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE ".OTHER(Specify) IMk 4&k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET ,3.STRIKER PLATEMOTTOM PROTECTOR 4.CONTAINMENT SUMP 451.. VII.UNDER DISPENSER CONTAINMENT(UI o CONSTRUCTION TYPE I.SINGLE WAIL [32.DOUBLE WALL ❑ 3.NO DISPENSERS E390.NONE 469. CONSTRUCTION MATEJUAL I.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC 99.OTHER(S ) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 418. UL APPLICANTSIGNATURE CERTIFICATION: 1 certify that this IJST system is compatible with the hazardous subsume stared and that the halm oration provided hereto is true,taurate, and in full ith 1 al ulre t&- APPLICANTSIGNATURE DATE 4m APPLICANT NAME(prmt)" l� 471. APPLICANT TITLE 1 4n. Ll UPCF UST-B-1/2 Rev.1-12-4