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8D < my) UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK FAoo i D.3 35 1)Q OPERATING PERMIT APPLICATION-TANK INFORMATION (Ona form per U T) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11,111,ry and IX below) 430 ❑ I.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', 430, 1 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION /S FACILITY ID#(Agency Use Only) 1. BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) BUSINESS SITE ADDRESS �U3. CfTY l94_ ws-�^r41 ,i II. TANK DESCRIPTION TANK ID It 432. TANK MANUFACTURER 433- TANK CONFIGURATION:THIS TANK IS 434. ❑ 1,A STAND-ALONE TANK Compleiv can page for each ❑ 2.ONE IN A COMPARTMENTED UNIT compmmam Nv.ma DATE UST SYSTEM INSTALLED 435, TANK CAPACITY IN GALLONS 436, NUMBER OF COMPARTMENTS IN THE UNIT 437, SO DO III. TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE dab.HAZARDOUS WASTE(Iedodm Thad OIO ❑ 5.EMERGENCY GENERATOR FUEL[HSC 4252913(c)] ....................__Q 6_OTHER GENERATOR FUEL ❑ 95._UNKNOWN 99.OTHER(�ecifY): 439x, CONTENTS PETROLEUM: ❑ 1&REGULAR UNLEADED ❑ Ie.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 4404. NON-PETROLFUM'a 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM($ i ): 4491. IV. TANK CONSTRUCTION TYPE OF TANK _ _ O. 1._SiNGLE WALL ❑ 2.DOUBLE WALL _,.895 UNKNOWN 443 PRIMARY CONTAINMENT ❑ I.STEEL [13.FIBERGLASS ❑ G INTERNAL BLADDER ub ❑ 7,STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER S i ): 444a SECONDARY CONTAINMENT ❑ L STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNXNOWN ❑99.OTHER(S.Mify)_ 4459 OVERFILL PREVENTION ❑ I.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING_CONSTRUCTION _ ❑ 1SING,E WALL_❑,2_DOUBLE WALL.,,..QBOIHER 460. SYSTEM TYPE ❑ LPRLSSURE _Q 2 GRAVITY _[1 3 CONVENTIONAL.SUCTION ❑ 4 SAFE SUCTION(23 CCR 6263f1(ax3)L.- 438 PRIMARY CONTAINMENT ❑ I.STEEL [14.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10,RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHERS ): > SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify); 464c. _- _.__..... . PIPINGi7URBTNE CONTAINMENT SUMP TYPE [11.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE C64e VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): gbq,l VENT SECONDARY CONTAINMENT [3I.STEEL ❑ 4.FIBERGLASS C110.RIGID PLASTIC ❑ 90.NONE [I 99.OTHER(Specify): d6�; VR PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4s4a VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): n644hh' VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): q46 j_ RISER SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Speafy): q4"k FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATEMOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 4 Ire VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS 90.NONE _ 469e ...._..___-..__________ CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) d6�' VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 449. IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the Information provided herein is true, accurate and in full compliance with legal requirements. APPLICANT SIGNATURE DATE 470 APPLICANT NAME(print) 171 APPLICANT TITLE 47Z UPCF UST-B,Rev.(122007)-112 www.unidocs.org