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• • • r1 a 1101111 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 L 11, 111, IV, and IX helow) 430. ❑ 1. NEW PERMIT ❑ 3. RENEWAL PERMIT 9 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: 4301,. I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) - - 1. BUSINESS NAME (Same as Facility Name or DRAA - Doing Business As) 3. 7� SGn Jd�en �4 rOim� �(rKlet sL/157Yt[,T BUSINESS SITE A&M 103. CITY 104 /S33 v- II. TANK DESCRIPTION TANK ID # -`AO 11 ( 432. TANK MANUFACTURER 433. TANK CONFIGURATION: THIS TANK IS 434. DL( .9 L A STAND-ALONE TANK C.Wleteonepe,cforeech /1f0 " B.jO IZ/ eats ❑ 2. ONE INA COMPARTMENTED UNIT wmparnte Gt the wit. DATE UST $YST M INSTALLED 435. TANK CAPACITY IN GALLONS 036 NUMBER OF COMPARTMENTS IN THE UNIT 437 ✓r//a�2 20 ®DD III. TANK USE AND CONTENTS TANK USE la. MOTOR VEHICLE FUELING ❑ Ib. MARINA FUELING ❑ Ic. AVIATION FUELING 439_ 3. CHEMICAL PRODUCT STORAGE ❑4. HAZARDOUS WASTE uii Cc[des Used Oip ❑ 5. EMERGENCY GENERATOR FUEL [HSC §25281.5(c)I ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439. CONTENTS PETROLEUM: ❑ la. REGULAR UNLEADED ❑ I.. MIDGRADE UNLEADED ❑ lb. PREMIUM UNLEADED 44U. X 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ S. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (Specify): 440x. NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ❑ 11. OTHER NON -PETROLEUM (S ccify): 4406. IV. TANK CONSTRUCTION TYPE OF TANK❑ I. SINGLE WALL_ 2 WALL ❑ 9 U\KNOW] 443- _--. .._......._... .. ....._..._..__ _DOUBLE _-- ..__.... .._. ...._._._.- --_---""._ .._.. PRIMARY CONTAINMENT El L STEEL (� 3. FIBERGLASS ❑ 6. (STERNAL BLADDER 444. ❑ 7. STEEL INTERNALLINING ❑ 95 (INKNOWN ❑ 99. OTHER (Specify): 4aia STEEL 3. OR MEMBRANE LINER ❑ ]. JACKETED 445. SECONDARY CONTAINMENT FIBERGLASS 0 90. NONE ❑ 95 UNKNOWN E1 99 OTHER (Specify): 445a. .._... OVERFILL PREVENTION ❑ LAUDIBLE &. 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 ❑ I: SINGLE WALL ($2 DOUBLE WALL ❑ 99. OTHER 460. SYSTEM TYPE 1. PRESSURE_ Ll 2_GRAVITY ❑ 3 CONVENTIONAL SUCTION ❑ 4 SAFE SUCTION [23 CCR §i636(eH>)]-,_ 458. PRIMARY CONTAINMENT ❑ 1. STEEL X4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464. ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464_% SECONDARY CONTAINMENT ❑ L STEEL 0 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 4646. ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464c. PIPINGlI'URBINE CONTAINMENT SUMP TYPE ❑ I. SINGLE WALL 2. DOUBLE WALL ❑ 90. NONE 464x. VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION 46 VENT PRIMARY CONTAINMENT L STEEL El 4. FIBERGLASS [I10. RIGID PLASTIC [I90. NONE ❑ 99. OTHER (Specify): 464.. VENT SECONDARY CONTAINMENT )$ 1. STEEL [14. FIBERGLASS El 10. RIGID PLASTIC [190. NONE El 99. OTHER (Specify): 4640. VR PRIMARY CONTAINMENT a 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): a� � VR SECONDARY CONTAINMENT A 1. STEEL - ❑ 4. FIBERGLASS ❑ HE RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 4�hl. VENT PIPING TRANSITION SUMP TYPE ❑ 1. SINGLE WALL ❑ 2. DOUBLE WALL 25 90. NONE 464i RISER PRIMARY CONTAINMENT CK L STEEL [14. FIBERGLASS [110. RIGID PLASTIC El90. NONE El99.OTHER (Specify): V"4464j- RISER SECONDARY CONTAINMENT P( 1. STEEL [14. FIBERGLASS El 10. RIGID PLASTIC C190. NONE ❑ 99. OTHER (Specify): 464k: FILL COMPONENTS INSTALLED X 1. SPILL BUCKET ❑ 3. STRIKER PLATElBOTTOM PROTECTOR ❑ C CONTAINMENT SUMP 411 - VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE 1. SINGLE WALL 2. DOUBLE WALL 0 3. NO DISPENSERS ❑ 90. NONE 469'. _ _ _ _0 CONSTRUCTION MATERIAL ❑ 1. STEEL [34. FIBERGLASS I& 10. RIGID PLASTIC [199.99.OTHER (Specify) 469c 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 a" full compliance with #gid requirements. APPLICANT SIGNATURE DATE -777/,7z5?9' 470. 471, APPLICANT NAME (print) �«( APPLICANTTITLE 6'S s1/�uy-isY•►.��s7�- 472 ©� UPCF UST -B Rev. (12/2007) -1/2 www.unidocs.org