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zo8b� Lo/ UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK rproDfD..3 OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. For a UST claswe or removal,complete only this section and Sections I,/!,Ill,N,and LYhelow) 430. ❑ L 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) 3. BUSINESSNAME(Same as Facility Name or DBA-Doing Business As) BUSINESS SITE ADDRESS 103. CITY 104. II. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. ❑ L A STAND-ALONE TANK Complete one page far each ❑ 2.ONE INA COMPARTMENTED UNIT compeement is the it DATE UST SYSTEM INSTALLED 435, TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437 '50042 III. TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Jr.AVIATION FUELING 434 ❑ 3.CHEMICAL PRODUCT STORAGE � d.HAZARDOUS WASTE(Inclades Lead Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(1)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439. CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ IF.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440. NON-PETROLEUM 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL_❑ 2.DOUBLE WALL 695,UNKNOWN PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER($ eci : 444. SECONDARY CONTAINMENT ❑ L STEEL [13.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LMER ❑ 7.JACKETED 445. ❑ 90.NONE _❑ 95.UNKNOW_N ❑99.OTHER(Specify): Ms. OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 453. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 99.OTHER 460. SYSTEM TYPE_ (] ].PRESSURE _0_2.GRAVITY ❑ 3.CONVENTIONALSUCTION ❑ 4.SAFE SUCTION 2CeR42636O(3) - 458. PRIMARY CONTAINMENT [11.STEEL [14.FIBERGLASS [18.FLEXIBLE [110.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464b. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4641. PIPINGnURBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46641. VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): fl VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464 g VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): hj_ VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 461i' RISER PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46141 j_ RISER SECONDARY CONTAINMENT ❑ L STEEL El4.FIBERGLASS El10.RIGID PLASTIC [190.NONE [199.OTHER(Specify): 413,lkkl FILL COMPONENTS INSTALLED ❑ L SPILL BUCKET ❑ 3.STRIKER PLATEBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 4514-c. VII. UNDER DISPENSER CONTAINMENT (UDC) _CONSTRUCTION TYPE ❑ 1.SINGLE WALL _ ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 4 90.NONE 469 CONSTRUCTION MATERIAL ❑ ].STEEL El4.FIBERGLASS El 10. RIGID PLASTIC ❑ 99.OTHER(Specify) 4691. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I 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) 411. APPLICANT TITLE 472. UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org