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• 01 UNIFIED PROGRAM CONSOLIDATED FORM ' UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. ForUST permanent closure or removal,complete only this section and Sections 1,II,III,IV,and IX below) 430 1.NEW PERMIT 671 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430s DATE EXISTING UST DISCOVERED: 43ob L FACILITY INFORMATION FACILITY ID 0(Agency Use Only) G,, ' t BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 a- L---A.Ti-i2or y.> BUSINESS SITE ADDRESS t03 CfI Y 104 1 L Eb l c7 II.TANK DESCRIPTION TANK 11)# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 El1.A STAND-ALONE TANK _ F P-o S C as Q 2.ONE IN A COMPARTMENTED UNIT. Complete OWENC for ewh corn in the wk DATE YST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 III.TANK USE AND CONTENTS TANK USE '0 la.MOTOR VEHICLE FUELING ❑ ]b.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4,HAZARDOUS WASTE(Includes tied Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: 13 Ia.REGULAR UNLEADED ❑ ]c.MIDGRADE UNLEADED ❑ ]b.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.IET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ l 1.OTHER NON-PETROLEUM(Specify); Wb IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT � I. ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN 0 99.OTHER (S i ): 444a SECONDARY CONTAINMENT El 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.3ACKETED 445 ❑ 90,NONE 95.UNKNOWN ❑99.OTHER S 4453 OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT kr 3.FILL TUBE SHUT-OFF VALVE 452. 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFJLC PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑I.SINGLE-WALLED 12 2.DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE ® I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4,SAFE SUCTION 123 CCR 12636(a)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL ® 4,FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(SpeciPy): 464a SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE 7W 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.'VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE 0 99,OTHER(Specify) 464e VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f Oran VR PRIMARY CONTAINMENT ❑ 1.STEEL J�j 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464g 464 l VR SECONDARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE I.SINGLE WALL 2.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90,NONE 99.OTHER(Specify) 464j 464j[ RISER SECONDARY CONTAINMENT I.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464k 464kl FILL COMPONENTS INSTALLED 1.SPILL BUCKET J@ 3.STRIKER PLATEIBOTTOM PROTECTOR C1 4.CONTAINMENT SUMP 451a-c VII.UNDER DISPENSER CONTAINMENT.(UDC) CONSTRUCTION TYPE -1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 4693 CONSTRUCTION MATERIAL L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 94.OTHER(Specify) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 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 le al r uiremeets. APPLICANT SIGNATJJ!!::;�:�� - DATE470. d)�yr�r APPLICANT NAME(Print) 471. APPLICANT TITLE 47-1. 4h)i L Z/4 WI 54,A06 CW 7--e[)4- UPCF UST-8-1/2 Rev.(12/2007)