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• tr - UNIFIED PROGRAM CONSOLIDATED FORM I I UNDERGROUND STORAGE TANK OPERATING PERNUT APPLICATION-TANK INFORMATION (One formper UST) OF ACTION (Check one item only. Fora UST closure or removal,complete only this section and Sections 1,ll,N,lI,aad TX helow) 430. 1.NEW PERMIT ❑ 3.RENEWAL PERMJ] ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7,UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4304 DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION ._ FACILITY ID#(Agency Use Only) - - _- BUSINESS NAME(S eas FaciliryN or DBA-Ting iness As) aI. Z 3. BUSINESS SITE ADDRESS V 103. CITY Iby. / 1 ClJ mainGIC tL/1 1 !/- II. TANK DESCRIPTION TANK ID# / tS]^43z. TANK MANUFACj p 3NFIGURATION: THIS TANK IS 434. ASTAND-ALONE TANK Onnplue-apse taeach DATE UST SY TE INSTALLED 435. TANK CAPACITY IN GALLONS 436. 2.ONE EVA COMPARTMENTED UNIT caWmnent in t1e air NUMBER OF COMPARTMENTS IN THE UNIT 437. 5c u III. TANK USE AND CONTENTS TANK USE ❑ I a.MOTOR VEHICLE FUELING ❑ I b.MARINA FUELING ❑ 3.CHEMICAL PRODUCT STORAGE ❑ Ic.AVIATION FUELING 439. ❑ 4.HAZARDOUS WASTE(Includes Used Oil) El�55 EMERGENCY GENERATOR FUEL(FISC§25181.5(c)] ❑ 6.OTHER GENERATOR FUEL __�95.UNKNOWN 6599.OTHER(Specify): Q( I g39a CONTENT$ PETROLEUM: ❑ 3.DIESEL UNLEADED ❑ Ic.MiDGRADE UNLEADED ❑ I PRPREMRIM UNLEADED Mo. ❑ 3.DIESEL ❑ 5„IET pUEL ❑ 6.AVIATIO�GAS _ ❑ 8.PETROLEUM BLEND FUEL .OTHER PETROLEUM(SpeHy):- AJ.pk] Or 440a NON-PETROLEUM: 7,USED OTL ❑ 10.ETHANOL ------------- ❑ IL OTHER NON-PETROLEUM(Speciy): 440b, IV TANK CONSTRUCTION, TYPE OF TANK _-__ (] 1 SINGLE WALL 2.DOUBLE WALL ❑ 95 UNKNOWN PRIMARY CONTAINMENT ,STEEL 443. ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER ❑ 7.STEEL+EV'1'ERNAL LEVEVG _ 0 95.UNKNOWN ❑ 99.OTHER(Specify): 4444 SECONDARY CONITAINMENT .STEEL ❑3.FIBERGLASS ❑ 6.EXTERIORMEMBRANE LINER ❑ 7.JACKETED -445.- �,90.NONE 095.UNKNOWN ❑99.OTHER(SpectCy): 4454 OVERFILL PREVENTION ❑ 7.AUD]BLE&VISUAL ALARMS .BALLFLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE -452. ❑ 4.TANK MEGTS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION E UIPMENT V. PRODUCT/WASTE PIP_ING CONS_TRUCTIO PIPING CONSTRUCI ION I SINGLE W ALL ❑ 2.DOUBLE WALL m -.. �,` -_ _ 0.99.OTHER 46(. SYSTEM TYPE _ Hy,,pRESSURE 0 2 GRAVITY ❑ 3_CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(aX3)] 45A PF EvfARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ I.STEEL 4,FE3ERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4691 ❑ 90.NONE _ 95.UNKNOWN 1199 R OTHES(Specify): 4M.PIPING/I'URBINE CONTAINMENT SUMP TYPE 1.SA`GLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4694. VI. VENT, VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1. TEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464e VENTSECONDARY CONTAINMENT /gS-TEEL °64`I' LW1. ❑ 4.FIBERGLASS ❑ 10,RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): VR PRIMARY CONTA]NIMENT 4698. _ ❑ 1.STEEL ❑ 4.FE3ERGLASS ❑ 10.AIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): VR SECONDARY CONTAINMENT -- - 464 ❑ 1.STEEL ❑ 4.FIEERGLASS_0 ]0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 0.691 VENT PIPING TRANSTTION SUMP TYPE 41 ❑ 1.SEVGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONB 464. RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FE3ERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify):-- 4 -.I RISER SECONDARY CONTAIlVMENT -- 46411. ❑ LSTEEL ❑ 4.FESERGLASS ❑ ILRIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(S,c.y)r 4k ❑ 3.STRIltER PLATE/BOTTOM PROTECTOR F1 4.CO PILL COMPONENTS PJSTALLBD ❑ 1 SPILL BUCKET - E. MAINMENT SUMP VII. UNDER DISPENSER CONTAINME C CONSTRUCTION TYPE _0 I SINGLE WALL ❑ 2.DOL BLE WALL_ ❑ 3 NODISPENSFRS ❑ 90 VONE 469. CONSTRUCTION bIALPRIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ IO.RIGIDPLASTIC ❑ 99.OTHER(Spmify) 4696. 46% VIIL CORROSION PROTECTION SFEELCOMPGNENTPROTECTION ❑ 2.SACRIFICIAL ANODES) ❑ a-IMPRESSED CURREJT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE - CERTIFICATION: I certify that this UST system is compatible with we hazardous Substance stored and that the information prmided herein is true, accurat d In full m ce with Ie air u]rements. APPLICANT SIGNATURE I DATE IMA 2D1 I] 420. APPLICANT NAME(print) 471' ApPLIC TTTL� 422. UPCF UST-B Rev.(72/2007)-I/2 www.lmidocs.org