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11 • r 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, 7V, and LY below) 430 j ❑ 1. NEW PERMIT ❑ 3. RENEWAL PERMIT 0 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 FACILITY ID # (Agency Use Only) _ _ 1. BU�SIN5ESS NAME '(Same as Facility Name or DBA- Doing Business As) 3. �lS�/Y�� CJ Qit J d Jrn ��i'� %✓Y1"ep<s r' BUSINESS SITE AD_D SS 103 CITY 104. / .53 3 i. Lln?6 ST' 5%OGk 70 r U. TANK DESCRIPTION TANK ID # -T-gO(1 S$ 432. TANK MANUFACJiLRER 433- TANK CONFIGURATION: THIS TANK IS 434. NO /O r(6 _0380 (�O �Y C Q��S, � ❑ L A STAND-ALONE TANK C.Mleteone Pass fos each 2. ONE M A COMPARTMENTED UNIT wmpanmmtin the it DATE UST YS EM INSTALLED 435. TANK CAyyACITY IN GALLONS 436- NUMBER OF COj�v41PARTMENTS IN THE UNIT 437. S�a�Z lj 000 L III. TANK USE AND CONTENTS TANK USE ❑ Is. MOTOR VEHICLE FUELING ❑ Ib. MARINA FUELING ❑ IC. AVIATION FUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 5. EMERGENCY GENERATOR FUEL [HSC 425281.5(c)] ❑ 6. OTHER GENERATOR FUEL _ ❑ 95. UNKNOWN )K 99. OTHER(SpecOO: /ro 4439. CONTENTS PETROLEUM: ❑ Is. REGULAR UNLEADED ❑ I.. MIDGRADE UNLEADED ❑ Ib. PREMIUM UNLEADED 440_ ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS 1Q ,T��T ____ __ __ ___ ❑ 8. PETROLEUM BLEND _FUEL �'. OTHER PETROLEUM(Specify)WON • ISL*Olea/ - ✓tI-�'a' SiL'y Ots- _Uri). NON-PETROLEUM: ❑ 7. USED OIL ❑ 10. ETH OL 11. OTHER NON -PETROLEUM (S eci ): ✓G+a_S a+aSSao� �LU4 4406. IV. TANK CONSTRUCTION TYPE OF TANK ❑I.SINGLEWALL 2.DOUBLEWALL El 95. UNKNOWN _- - _ _.............._.._.____ PRIMARY CONTAINMENT ❑ I. STEEL K 3 FIBERGLASS ❑ 6. INTERNAL BLADDER ❑ 7. STEEL+ INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER(Specify): 444. SECONDARY CONTAINMENT ❑ 1. STEEL 43. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445_ ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 445. OVERFILL PREVENTION ❑ 1. AUDIBLE & VISUAL ALARMS ❑ 2. BALL FLOAT A 3. FILL TUBE SHUT-OFF VALVE 452. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT / WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION (] 1 _SINGLE WALL DOUBLE WALL ❑ 99 OTHER 460, _X2., SYSTEM TYPE ❑ 1. PRESSURE _ [I 2. GRAVITY j+�' 3 CONVENTIONAL SUCTION ❑ 4 SAFE_SUCTION j•23 CCR §2636 a 3 458. PRIMARY CONTAINMENT ❑ 1. STEEL IK4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464. ❑ 90. NONE ❑ 95. UNKNOWN El 99. OTHER(Specify):. 4640 ....___..- .......____._ __FLEX__ _.. SECONDARY CONTAINMENT ❑ L STEEL ❑ 4. FIBERGLASS ❑ 6. FLEXIBLE ❑ 10. RIGID PLASTIC 4646 __E El 90 NONE -E -_ ❑ 95. UNKNOWN _ _ El_99. OTHER( 464c C__ PIPINGn BANONTAINMENT SUMP TYP❑ 1. SGLE WALL ❑ 2. DOUBLE WALL El90. NONE 464d_ URIN 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): 46441. VENT SECONDARY CONTAINMENT (�. I. STEEL ❑ 4 FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): y°�B, .... - VRPRIMARYCONTAINMENI I. STEEL ❑ 4 FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90 NONE ❑ 99. OTHER (Specify): Q4f' . VR SECONDARY CONTAINMENT I. STEEL ❑ 4_FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90 NONE ❑ 99 OTHER(Specify): 454h1, __- VENT PIPING TRANSITION SUMP TYPE ❑ I. SINGLE WALL ❑ 2 DOUBLE WALL 990 NONE �` RISER PRIMARY CONTAIN MFNT I STFFI ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify), ab"i, RISER SECONDARY CONTAINMENT I. STEEL ❑ 4. FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464k1' FILL COMPONENTS INSTALLED 1. SPILL BUCKET ❑ 3. STRIKER PLATE/BOTTOM PROTECTOR ❑ 4. CONTAINMENT SUMP 451s -c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ❑ 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS 90. NONE 4690. CONSTRUCTION MATERIAL ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 4696. P f) 469c VIII. CORROSION PROTECTION X448. STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION 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 an ' ull compliance with legal requirements. APPLICANT SIGNATURE DATE -71,40P 57 470, 471. APPLICANT NAME (print) L APPLICANT TITLE --G!� rK� Sv y[Ky4� 72 h UPCF UST -B Rev. (12/2007) -1/2 www.unidocs.org EN