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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One temper UST) TYPE OF ACTION (Check one item only. For anyST permanent closure or removal,complete only this section and Sections I,II,IB,IV,and IX below) 430 ❑ ],NEW PERMIT 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: V30a I DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID N(Agency Use Only) I BUS SS NAME(Saing as FACILi AMEr D oin as As) r 3 LC a, r1 5 1 L1�� DBA- JvC S vEI, A_A:a BUSINESS SITE ADDRESSis j y§&A`)W CFI'Y UA11r p p 104 II.TANK DESCRIPTION ) 1\t"l TANK ID H 432 TANK MANUFACTURER 433 TANK CONFIGURATION: TMS TANK IS 434 A STAND-ALONE A NK ONE IN A COMPARTMENTED UNIT. Com late me Raise for each com artmeel in the mdt. DATE UST SYSTEM INSTALLED 435 TANK CAPACI YIN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 ec 3 III.fANK USE AND CONTENTS TANK USE ❑ Ia.MO"I'ORVIHICLE FUELING ❑ Ib.MARINA FUELING ❑ .A VIA TION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE El 4.HAZARDOUS WASTE(lnduda Used Oil EMERGENCY GENERATOR FUEL IHSC§25281.5(c)I [16.OTHER GENERATOR FUEL ❑ 95,UNKNOWN 99.OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ I REGULARUNLEADED ❑ I..MIDGRADE UNLEADED Cl 1b.PREMIUM UNLEADED 440 0%i.DIESEL ❑ 5.JET FUEL Cl 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4466 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALLUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL LA.14,F ERGLASS ❑ 6.INTERNAL BLADDER 444 [l7.STEEL+INTERNAL MG El 95.UNKNOWN ❑ 99.OTHER (Specify): 444. SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(SpecifOv 445. OVERFILL PREVENTION ❑ I.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT .FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUC /WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1,51 NGLE-WALLED .DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE .PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(.X3)1 458 PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Sp.&y): 4". SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95. KNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE EL117.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4Md VI.VENT,VAPO COVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464c 64.1 VENT SECONDARY CONTAINMENT 1.STEEL ❑ 4 FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT ❑ 1.STEEL IV 4 IBERGLASS Lj 10,RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464 1 VR SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 9 .NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑7.'SINGLE WALL [12.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT V L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 0.NONE ❑ 99.OTHER(Specify) 464, 414,1 RISER SECONDARY CONTAINMENT [I ].STEEL [14.FIBERGLASS [110.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4641 46411 FILL COMPONENTS INSTALLED 1.SPILL BUCKET El 3.STRIKER PLATEIBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a-= VII.UNDER DISPENSER CONTAINMENT(U CONSTRUCTION TYPE SINGLE WALL [12.DOUBLE WALL 3.NO DISPENSERS ❑ 90.NONE 469. CONSTRUCTION MATERIAL L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448 IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify t t this UST system is compatible with the hazardous substance stored and that the information provided her _;Itrue,accurate, and in fu com a e with legal requirements. APPLICANT SIGNATURE DATE U ! C.J CI Q . 470. APPLICANT NAME(print) a! A O a I 491, APPLICANT TITLE) f(,/� �0 472. P el... UPCF UST-B-1R Rev.(12/2007) 4,,!!