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UNIFIED PROGRAM CONSOLIDATED FORM j UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One co m r below) 430 UST) / TYPE OF ACTION (Check one item only. Foran UST permenent closure or removal,complete only this section ❑ 1.NEW PERMIT [1 3. Sections I,11,111,IV,and 3.RENEWAL PERMIT ❑ 5.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: 4)Ob FACILITY ID#(Agency Use Only) L FACILITY INFORMATION _ 1 BUKBVESS NAME(S4al.m�.�e.4,as FACILITY NAME or DBA-Doing Business As) 3 /4'3 Ul'.tY rJ P - -?.-r �'-h Cr rls L-LC, l7 BUSINESS SITE ADDRESS 103 CTTY '^ ( 104 U.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TAW CONFIGURATION: THIS TANK IS 434 al.A STAND-ALONE TANK DS 1 ❑2.ONE IN A COMPARTMENTED UNIT. DATE UST SYSTEM INSTALLED a33 C 1"fO1L f°" rota wuL TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 III.TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ !c.AVIATION FUELING 439 >j3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE ryrJ Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑95.UNKNOWN 13 POTHER Sped ): g39a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE LNLEADED ❑ Ib.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION O n ' ❑ S.PETROLEUM BLEND FUEL GAS 9.OTHER PETROLEUM NON-PETROLEUM:(] 7.USED OIL ❑ 10.ETHANOL I�I{3 IL OTHER NON-PETROLEUMS Wi 440E S TV. TANKCONSTRUCTION Ivy TYPE OF TANK A.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN PRIMARY CONTAINMENT L STEEL443 ❑ 3.FIBERGLASS ❑ 6.INERNAL BLADDER 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99,OTHER S SECONDARY CONTAINMENT L STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED qq5 90.NONE ❑ 95.UNKNOWN L94-99 OTHER(Specify): IJ µ5a OVERFILL PREVENTION y I.AUDIBLER VISUAL ALARMS 2.BALLFLOAT 3.FILLTUBESHUT- r(>l4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT FF V. 45= V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 21.SINGLE-WALLED ❑2.DOIIBLE-WALLED ❑99,OTHER SYSTEM TYPE I.PRESSURE ❑ 2.GRAVf1Y PRIMARY CONTAINMENT I.gTE� ❑ 3.CONVENTIONAL SUCTION 4.SAFE SUCTION[L3 CCR 2636(s 3) 458 ❑ 4.FIBERGLASS X 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4µ ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 961. SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.F ❑ 10.R[GID PLASTIC 464b 90.NONE ❑ 95.UNKNOWN ❑ 99.OT11ER(Speeify): 4 PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ LSINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS 0 l0.RIGm PLASTIC 90.NONE 99.OTHER(Specify) 464e VENT SECONDARY CONTAINMENT LSTEEL U 4.FIBERGLASS 0 10.EIGIDPLASTIC W.NONE U 99.OTHER(Specify) 464f VR PRIINARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Spccify) 4&µn VR SECONDARY CONTAINMENT ❑ 1.STEEL Lj 4.FIBERGLASS Ll 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464,1 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NO X461 RISEA PRN4ARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGIB PLASTIC 90.NONE 99.OTHER(Specify) 4µT RISER SECONDARY CONTAINMENT I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Spaify) 4µk FILL COMPONENTS INSTALLED L SPILL BUCKET 0 3.STRIKER PLATE/BOTTOM PROTECTOR Fj 4.CONTANMENT SUMP /�ac VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ LSNGLE WALL ❑ 2.DOUBLEWALL ❑ 3.NO DISPENSERS 90.NONE 469. CONSTRUCTION MATERIAL ❑ L STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC U 99.OTHER(S i ) g6yb,e VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ,Q 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hamrdous Substance stored and that the Information provided herein is true,accurate, and In fn6 arom Bapce with 1 al ulremepb. APPLICANT SIGNATURE DATE 470, APPLICANT NAME(print) 4n. APPLICANT TITLE 472. UPCF UST-B-1/2 Rev.(12/2007)