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UNIFIED PROGRAM CONSOLIDATED FORM J UNDERGROUND STORAGE TANK2� OPERATING PERMIT APPLICATION-TANK INFORMATION(One form of UST) TYPE E ACTION (Check one item only. Foran UST permanent closure or removal,complete only this Section and Segions I,11,IH,IV,and IX bciow) 430 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ S.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4`* DATE EXISTING UST DISCOVERED: 43M I. FACILITY Y INFORMATION FACILITY ID p(Agency Use Only) _ 1 BU�INESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 /1 ^ 4 BUSINESS SITE Au fits, 103 `cam �J •-� _ CTIY l04 ...� L�..4 .rc ILTANKDESCREPTION TANK ma 4J2 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 7WP / �3D E I.A E I NA ALONECOMMA TANK ❑2.ONE M A COMPARTMENTED UNIT. DATE UST SYSTEM INS ALLED 43s °eOnC 1orah JeW°'. TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UN 37 �2 III.TANK USE AND CONTENTS TANK USE 0 la.MOTOR VEHICLE FUELING 0 lb.MARINA FUELING >t 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE on hu UxE OBI) 13[1 5. GENERATOR FUEL[HSC§25281.5(c)1 439 ❑ 6.OTHER GENERATORFUEL 0 95.UNKNOWN ❑ 99.OTHER (S 'fy); 43 ` I CONTENTS PETROLEUM: ❑ Ix.REGULAR UNLEADED 0 Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED ❑ I DIESEL ❑ 5.JET FUEL S 0 6.AVIATION GAS (,l �� Z� I`• ❑ B.PETROLEUM BLENDFUEL9.OTHER PETROLEUM ' S NON-PET03 ROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 11.OTHER NON-PETROLEUM S i 440h CA IV. TANK CONSTRUCTION. L TYPE OFT 1.SINGLE WALL 0 2.DOUBLE WALL ❑ 95.UNKNOWN A r, PRIMARY CONTAINMENT L STEEL 443 1v ❑ 3.FIBERGLASS ❑ 6.IMERNAL BLADDER 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN 0 99.OTHER (S SECONDARY CONTAINMENT ^ 1.STEEL ❑3.F®ERGLASS 0 6.EXTERIOR MEMBRANE LINER 7.JACKETED 4 1 V 90.NONE 0 95.UNKNOWN .OTHERE ): _V U0. 445a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FRL TUBE SHUT-OFF VALVE 4R. 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 1.SINGLE-WALLED ❑2.DOUBLE-WALLED 0 99.OTHER SYSTEM TYPE LPRESSURE 4W ❑ Z.GRAVITY ❑ 3.CONVEMTONAL SUCTION 4.SAFE SUCTION 23 CCR 426364 3) 458 PRIMARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS JK S.FLEXIBLE U10.RIG(D PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): y� SECONDARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS ❑ 8.FLEXIBLE 0 l0.RIGID PLASTIC 464h 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): *i, VI. TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE VI.VENT,VAPOR RECOVERY a6aa (VR}ANDRISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 9: NONE 99.OTHER(Specify) 46k VENT SECONDARY CONTAINMENT ❑ L STEEL U 4.FIBERGLASS ❑ 10.RIGID PLASTIC qj 90.NONE U 99.OTHER(Specify) 464f VR PRIMARY CONTAINMENT U 1.STEEL U 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4648 VR SECONDARY CONTAIN'..I U 1.STEEL U 4.FIBERGLASS G 10.RIGID PLASTIC90.NONE U W.OTHER(Spaify) 4641 VENT PIPING TRANSITION SUMP TYPEI.SINGLE WALL 2.DOUBLE WALL 90.NONE 464h1 RISEA PRIMARY CONTAINMENTU I.STEEL U 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONEj 99.OTHER(Specify) 4641 RISER SECONDARY CONTAINMENT Lj 1.STEEL U 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE99.OTHER(Spaify) 4611 FILL COMPONENTS INSTALLED L1 1.SPILL BUCKET 0 3.STRIKER PLATFIBOTTOM PROTECTOR 4.CONTAINMENT SUMP 4�t4 VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE OI.SINGLE WALL 02.DOUBLEWALL 03.NO DISPENSERS90.NONE 469. CONSTRUCTION MATERIAL ❑ L STEEL 0 4.FIBERGLASS ❑ 10.RICID PLASTIC ❑ 99.OTHER g69y,e VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES) ❑ 4.IMPRESSED CURRENT b.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stated and that the information proWded herein B true,accurate, In full compliance with legal r uiremeoss. APPLICANT SIGNATURE DATE 4M,, APPLICANT NAME(print) 471. APPLICANT TITLE 4T2. UPCF UST-B-12 Rev.(122007)