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UNIFIED PROGRAM CONSOLIDATED FORM 41 UNDERGROUND STORAGE TANK $/*�9 OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYP FACTION (Check one item only. For a(IST closure or removal,complete only this section and Sec Hou I,Il,III,IV,arsd LYbe7ow) pA 430. 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 4-� ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430. DATE EXISTING UST DISCOVERED: I. FACILITY INF_ ORMATION FACII,ITY ID#(Agency Use Only) - - -"'"`Q 1... J BUSINESS NAME me as FaeiliryN or DBA-Do'ngB mess As) 3. BUSINESS SITE ADDRESS 103. Cppy � 109 - II. TANK ID# C/y�3z -A11"SNAMANUFACTURER 433. TA *I1K CONFIGURATION:THIS TANK IS 4x.` ASTAND-ALONE TANK Comple4o pagefm earh DATE UST SYS IN 43s. �l •..) ❑ 2 ONE IN A COMPARTMENTED UNI'[ rampa<tment the wir TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. 7 Z o5 1500 III. TANK USE AND CONTENTS TANKUSE ❑ Ia.MOTOR VEHICLE FUELING ❑ IE MAR1NA FUELMG ❑ Ic.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE R4.HAZARDOUS WASTE(IndWee Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] [16.OTHER GENERATOR FUEL [195.UNKNOWN [j99.OTHER(Sp,cify): 439. CONTENTS PETROLEUM: ❑ la REGULAR UNLEADED 1.MIDGRADE UNLEADED ❑ 16.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ JET FUEL 6.AVIATIONGAS _ 0 8.PETROLEUM BLEND FUEL_[ 9,OTHER PETROLEUM(Specify):(Ae3%4SR oil 440. NON-PETROLEUM:❑ 7.USED OIL ------ ❑ SO.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION 7YPG_OF_TANK ❑ LSINGLE WALL_ 2 DOUBLE WALL ❑ 95.UNINiOWN 443. LY I.STEEL ❑ 3 FIBERGLASS ❑ fi.INTERNAL BLADDER 444,- __ ❑ 7. iEEL+1NTERNALLINING ❑ 95.UNKNOWN ❑ 99,OTHER(Specify): 444. SECONDARY CONTAINMENT ,STEEL ❑3.F®ERGLASS ❑ 6.EXTERIOR MEMBRANE L1NER ❑ 7.JACKETED 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S a' us. OVERFILL PREVENTION .AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452.- ❑ 4.TANK MEETS RE 1162EMET75 FOR EXEMPTTON FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONS[RUCTION 1 INGLB WALL ❑ 2.DOUBLE WALL ❑ 99.OTHER 46a. SYSTEM TYPE 1 PRESSURE ❑ 2.GRAVJTY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR 426 e3)] 458. PRM4AR11 CONTAINMENT ❑ 1,STEEL ❑ 4.FIBERGLASS ❑ 8.FEE ❑ 10.RIGIDPLASTIC 464. [I90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Speclfy): 464. SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ I0.RIGID PLASTIC 464b. ❑ 90.NONE ❑ 95.UNKNOWN 99_OTHER(Specify)- 464. PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4Md VI VENT, VAPOR RECOVERY (VR)AND RISER/FILL„PIPE PIPING CUNSTRUGTIO . VENT PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS 0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): aNe 464e1. VENT SECONDARY CONTAINMENT ❑ 1.STEEL [14.FIBERGLASS 0.RIGIDPLASTIC [190.NONEE El 99.OTHER(Specify): 469fl. VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.R[GID PLASTIC ❑ 90.NONe ❑ 99.OTHER(Specify): �� VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC 1190.NONE El99.OTHER(Specify): 4454h 464h1. VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL ❑ 2,DOUBLE WALL ❑ 90.NONE 4641. RISER PRIMARY CONTA]NMENT ❑ 1.STEEL ❑ 4.F®ERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99,OTHER(Specify): 46464 . RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4 I. 469kI. F ILL COb1PONENTS INSTALLED ❑ 1 SPILL BUCKET ❑ 3.STRIKER PLATE/BOTJOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a-c. VII UNDER DISPENSER CONTAINMENT (UDC) _ lOV TYPE _❑ 1 SI'v'CLE_WALL ❑ 2.DOl-ELE WALL CONSTRUCTION bIATERIAL. '- _. ❑ 3 NO DER(Sp LRS 469. ❑ 90 NONE_ ❑ 1.STEEL ❑ 4.FBERGLASS ❑ l0.RIGID PLASTIC ❑ 99.OTHER(SpcmCy) 469h VIII. CORROSION PROTECTION ; STEEL COMPONLN P PRO I-ECTION ❑ 2 SACRIFICL4L ANooE(s) ❑ a IMPRESSED cc]zRENT ❑ 6.ISOLATION 448 IX. APPLICANT SIGNATURE CERTIFICATION: i certify that this UST system is compatible with [he hazardous substance stored and that the information provided herein is true, accurate full li ce ith le al r uirements. APPLICANT SIGNATURE DATE n n ;), U 430. APPLICANT NAME(print) ,NS -_l 47L APPLIC Trot Y v CCE /�^A � `n 4M UPCF UST-B Rev.(12/200'7)-1/2 �" www.unidoes.org '- L C7�