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• • a UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK 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, It' and LY below) 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 4304, 1 DATE EXISTING UST DISCOVERED: 4301,. I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) 1. BUSINESS NAME (Same. as Facility Name or DBA - Doing Business As) 3. Sa.7 34i&Ffrted. /Ze �o.z� %/G.er.f l��sTl2rf BUSINESS SITE ADDRESS 103. X533 C. L.rr✓s si: CITY 104. -S7`oc��s II. TANK DESCRIPTION TANKID# .--r11O"r2$I 432. Aftraw O _ T O TANK MANUFACTURER 433. Dwe"f �tyP TANK CONFIGURATION: THIS TANK IS 434_ ❑I. ASTAND-ALONE TANK Complete one pace for each 2, ONE M A COMPARTMENTED UNIT companmmt in the unit. DATE UST SYSTEM INSTALLED 435. w/yZ TANK CAPACITY IN GALLONS 436. /, 000 NUMBER OF COMPARTMENTS IN THE UNIT 437_ 2. 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 (Include Used Oi) ❑ 5. EMERGENCY GENERATOR FUEL (HSC g2528L5(cp ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439. CONTENTS PETROLEUM: P( la. REGULAR UNLEADED ❑ Ic. MIDGRADE UNLEADED ❑ Ib. 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 ❑ II. OTHER NON -PETROLEUM (Specify): 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ I. SINGLE WALL 2. DOUBLE WALL _❑ 95. UNKNOWN 443. PRIMARY CONTAINMENT ❑ I. STEEL X 3. FIBERGLASS ❑ 6 INTERNAL BLADDER 444. ❑ 7. STEEL INTERNAL LINING 0 95. UNKNOWN ❑ 99. OTHER(Specify): 444.. SECONDARY CONTAINMENT ❑ L STEEL 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445. _❑ 9( NON_E95. UNKNOWN El 99. OTHER ecify): 445.. OVERFILL PREVENTION ❑ 1. 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 WALL 2. DOUBLE WALL ❑ 99. OTHER 460. -..... ... __.._ ..._-.. __ -- _ 1 _ - - _- PIPING CONSTRUCTION ElL SPRESSURE . GRAVITY 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR g2636(a)(3)1 458. SYSTEM TYPE CK 1. PRESSURE [1 2 ❑ PRIMARY CONTAINMENT ❑ 1. STEEL I>if 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464. SECONDARY CONTAINMENT ❑ 1. STEEL 9 4. FIBERGLASS ❑ S. FLEXIBLE ❑ 10. RIGID PLASTIC 4644 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 4Mc, PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL z DOUBLE wALL ❑ 90. NONE 464a. VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 46641 VENT SECONDARY CONTAINMENT IX 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 4flf VR PRIMARY CONTAINMENT 1% L STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 446a"a' VR SECONDARY CONTAINMENT 974 L STEEL El 4.FIBERGLASS [I HLRIGIDPLASTIC El90. NONE El99. OTHER (Specify): aha a6a11. .,.,_.,. VENT PIPING TRANSITION SUMP TYPE ❑ I. SINGLE WALL ❑ 2. DOUBLE WALL 90. NONE 4641. 4. RISER PRIMARY CONTAINMENT 9 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 4.46411 RISER SECONDARY CONTAINMENT Z I. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify):44k k FILL COMPONENTS INSTALLED X 1. SPILL BUCKET ❑ 3. STRIKER PLATEBOTTOM PROTECTOR ❑ 4. CONTAINMENT SUMP 451a -c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE I. SINGLE WALL _ _ _ ❑ 2_DOUBLE WALL_ 0 3 NODISPENSERS_[1 90. NONE 469a _ CONSTRUCTION MATERIAL ❑ I. STEEL ❑ 4. FIBERGLASS 10. RIGID PLASTIC ❑ 99 OTHER (Specify) J 9b. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION 448 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, a full compliance with le al requirements. APPLICANT SIGNATURE 470 DATE 7111 -log APPLICANT NAME (print) 471' APPLICANT TITLE 7` 472 _ UPCF UST -B Rev. (12/2007) -1/2 www.unidocs.org