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IFIED PROGRAM CONSOLIDATED F UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) ` TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections I,A III,IV,and a below) 430. ❑ 1.NEW PERMIT3.RENEWAL PERMIT [15.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE Q 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430.. 1 DATE EXISTING UST DISCOVERED: 436b. I. FACILITY INFORMATION FACll,ITY ID#(Agency Use Only) - - I BUSINESS NAME(So as Facility Name r,,nAA-DoPg Busi s AS) �/ 3. LCJ� BUSW SS SI AD KESS 103 CITY l04" 11 H. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER a 433. TANK CONFIGURATION:THIS TANK IS 434' T /� X on 1.A STAND-ALONE TANK Complete e page for each / �� ❑ 2.ONE BJ A COMPARTMENTED UNIT compartment in the mit. DATE UST SYSTPM INSTALLED .435. TANK CAPACITY IN GALLONS 430 1 NUMBER OF COMPARTMENTS IN THE UNIT 431. III.. GTANK USE AND CONTENTS TANK USEa.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING [I ]c.AVIATION FUELING 439. 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Uud Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§35281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER ISL=ify): 439. CONTENTS PETROLEUM: [3-1 a.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED �lb.PREMIUM UNLEADED 4`t(). ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify):_ ' NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ET7IANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL __DOUBLE WALL �._95_UNKNOWN 443' PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6 INTERNAL BLADDER ' ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Spec_fy): tea' SECONDARY CONTAINMENT ❑ 1.STEEL PD, FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED "5' ___ ______ ❑ 90.NONE LI 95.UNKNOWN ❑99.OTHER(Spmfy):. aa5. OVERFILL PREVENTION AUDBLE&VISUAL ALARMS 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-0FF VALVE 452. .TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL 2_1X)UBLE WALL_ Q 99_OTHER __"_ -___ qM" SYSTEM_TYPE ____ __ I.PRESSURE ❑. 2.GRAVITY _O 3.CONVINfIONAL SUCTION O_A SAFE SUCTION[23 CCR 458. _._.�_._..____ 464. PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS M,8.FLEXIBLE ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.0THER(specify): SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS t5d.FLEXIBLE ❑ 10.RIGIDPLASTIC 4 ' ❑ 90.NONE ❑ 95.UNKNOWN [3 99.OTHER(Specify): 4&I`' PIPING/T[JRBINE CONTAINMENT SUMP TYPE 1%4.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4 ' VI. VENT, VAPOR RECOVERY(VR) AND RISER/FILL PIPE PIPING CONSTRUCTION 464 VENT PRIMARY CONTAINMENT ❑ 1.STEEL 'W4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): g64e1. 464f. VENT SECONDARY CONTAINMENT ❑ 1.STEEL 1$.4.FIBERGLASS [j ]0.RIGIDPLASTIC ❑ 90.NONE [199.OT11ER(Specify): 464f1. - ____.____- 464& VR PRIMARY CONTAINMENT ❑ 1.STEEL �.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464 I. VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10_RIGID PLASTIC [390.NONE ❑ 99_OTHER(Specify): 446a4 hi. _____-____-___- - _.-- 464.. VENT PIPING TRANSITION SUMP TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL CV90.NONE 466.__- .-_______..._..___ -__._.... RISER PRIMARY CONCAINMENT ❑ 1.STEEL- Igo.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464'I. RISER SECONDARY CONTAINMENT ❑ 1.STEEL [34.FIBERGLASS [I10.RIGIDPLASTIC �M.NONE ❑ 99.OTHER(Specify): 4Mkki. FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR 3RCk CONTAINMENT SUMP 451a<. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE 1.SINGLE WALL _ ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a ___ _-___......___-...__--........_ 469b. CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 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. I om Hance w' uirem s. DATE 0/ O/ �9 470. APPLICANT SIGNATURE f7 APPLICANT NAME(print) 401' APPLICANT TITLE � G{® 472. v1 n IJ Ct UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org