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• • • • 0 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal, complete only this section and Sections 1, 11, 111, IV, and IX below) 430. ❑ 1. NEW PERMIT ❑ 3. RENEWAL PERMIT X5. CHANGE OF INFORMATION ❑ 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 4304 1 DATE EXISTING UST DISCOVERED: 4306. I. FACILITY INFORMATION FACILITY ID k (Agency Use Only) 1, BUSINESS NAME (Same as Facility Name or DBA- Doing Business As) 3. `BUSINESS S� vL�e_ ui g ,,- BUSINESSSITE AD SS 103. CITY IN 1,51-33 Zc ls��i� S7eoc6Fyarn II. TANK DESCRIPTION TANK ID 4 S`b ( 432. TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 TO O I 1 (Z/FitJ LO/n<i1 O Qq 1. ASTAND-ALONE TANK Complete one page for each /110=3-03�1�� ❑ 2. ONE IN A COMPARTMENTED UNIT campvtmmt In the unit. DATE UST SYSTE INSTALLED 435_ TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437 S-�lm QL Z -Or OOp III. TANK USE AND CONTENTS TANK USE la. MOTOR VEHICLE FUELING ElIb. MARINA FUELING ElIc. AVIATION FUELING 439. F 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Include; Uud Oil) ❑ 5. EMERGENCY GENERATOR FUEL MSC 425281 S(O] ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (S eci : 4394 CONTENTS PETROLEUM: la. REGULAR UNLEADED ❑ Ic. MIDGRADE UNLEADED ❑ Ib. PREMIUM UNLEADED 449, 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (Specte): 440a NON -PETROLEUM: ❑ ]. USED OIL ❑ 10. ETHANOL ❑ I1.OTHER NON-PETROLEUM(Speafy): 4406. IV. TANK CONSTRUCTION TYPE OF TANK ❑ I. SINGLE WALL2. DOUBLE WALL El 95. UNKNOWN 443_ PRIMARY CONTAINMENT ❑ I. STEEL A 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444- 0 7. STEEL+ INTERNAL LINING 95. UNKNOWN ❑ 99. OTHER(Specify): _ _❑ SECONDARY CONTAINMENT ❑ 1. STEEL 2(3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445. ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 445% OVERFILL PREVENTION ❑ I. AUDIBLE & VISUAL ALARMS ❑ 2. BALL FLOAT CK 3, FILL TUBE SHUT-OFF VALVE 452. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT / WASTE PIPING CONSTRUCTION PIPING C_ONSTR_U_C_TI.ON_ SINGLE WALL pt 2. DOUBLE WALL ❑ 99. OTHER 460, _ _ _❑_L SYSTEM TYPE �, I. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION 123 CCR §2636(4)(3) 458 PRIMARYCONTAINMENT ❑ I. STEEL IN 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 46,t ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464% SECONDARY CONTAINMENT ❑ L STEEL In 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 4646_ ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 4N4 PIPING% FURBINE CONTAINMENT SUMP TYPE ❑ I SINGLE WALL 8 2. DOUBLE WALL ❑ 90. NONE 464d_ VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1. STEEL Ll 4. FIBERGLASS El 10. RIGID PLASTIC El 90. NONE El 99, OTI IER (Specify): 46461. VENT SECONDARY CONTAINMENT ti 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Spe,,i6) 46Nf VR PRIMARY CONTAINMENT (9 I. STEEL ❑ 4. FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90. NONE ❑ 99.OTHFR(SpedfyC 16446' VR SECONDARY CONTAINMENT p( L STEEL El 4. FIBERGLASS EI 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. O I HER (SpeciE (. 464hh. VENT PIPING TRANSITION SUMP TYPE ❑ 1. SINGLE WALL ❑ 2. DOUBLE WALL ;, 90. NONE 4M` RISER PRIMARY CONTAINMENT 1 STEEL ❑ 4. FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Spcci fy): 46,11. RISER SECONDARY CONTAINMENT 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 4bp1- FILL COMPONENTS INSTALLED J9 L SPILL BUCKET ❑ 3. STRIKER PLATE/BOTTOM PROTECTOR ❑ 4. CONTAINMENT SUMP 451a,. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE kt 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 469a. CONSTRUCTION MATERIAL ❑ L STEEL ❑ 4. FIBERGLASS r�( H) RIGID PLASTIC ❑ 99. OTHER (Specify) 666. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION 448 M APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided hereif s. triol, accurate, an"full falpliance with legal requirements. APPLICANT SIGNATURE DATE ;? l6 Q92470 APPLICANT NAME (print) d vh 471. APPLICANTTITLE ��GlolT�t.Y ✓V/a/S 4n. UPCF UST -B Rev. (12/2007) -1/2 www.unidocs.org