BILLING 2010-2014 - Laserfiche WebLink

Home Browse Search

J UNIFIED PROG CONSOLIDATED FORM r UNDERGROUND STORAGE TANK l n y/ OPERATING PERMIT APPLICATION- TANK INFORMATI vz I " fmm per UST "TE OF ACRON (Check one item only. Fosean UST permanent closure orremoval, complete only Ws section and Sections I, 11, III, IV, and IX belOw)� 430 ❑� 1. 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: /Z Q/- /3 1341I DATE EXISTING UST DISCOVERED: 430b ' r .-,� .. .. . ., a..:.:::. .... '.. -.:n GTP '.1 V X . > r y PACILIT I ID # (Agency Use Only) r BUSINESS NAME (Same as FACH.ITY AME or DBA-Doing Business As) 544) S ✓J.J / est/ ✓/1 ! ✓f 19 S 1 7 3 BUSINESS SITE ADDRESS 103 CITY w TANK ID N 432 xvi T,AyNr.K. 'MANI IVARER / 433 TANK CONPIGURATION THIS TANK IS Cn0,Z.J 434 � r❑ry-1�.I,. ASTAND-ALONE TANKtC4ce�S an+.. ONE IN A COMPARTMENTED UNIT. C DATE UST SYSTEM STALLE 43s hZ Cao mono .mocha tin theoric TANK CA �C1Ty q1 CAI. 4M NUI�ER OF IT / I K4 L✓ 4n .FHFUELIN TANK USE .Ela. MOTOR VEHICLE FUELING ❑ Ib. MARINA FUELING µ ❑ Ic AVIATI G 439 EI 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (eeludn Used Oil) ❑ 5. EMERGENCY GENERATOR FUEL (HSC 125281.5(c)) ❑ 6.OTHER GEN OR FUEL ❑ 95. UNKNOWN (]' 99.OTHER (Speciry): 43% CONTENTS PETROLEUM: I a. REGULAR UNLEADED ❑ Ic. MIDGRADE UNLEADED ❑ Ib. PREMIUM UNLEADED 440 . DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑9.OTHER PETROLEUM(Specify): NON-PEMOLEUM:I] 7. USED OIL ❑ 10. ETHANOL aam I L OTHER NON-PETROLEUMS eci 14406 TYPE OF TANK LJ I. SINGLE WALL 2. DOUBLE WALL ❑95.UNKNOWN PRIMARY CONTAINMENT ❑ I. STEEL (a..3. FIBERGLASS ❑ 6. INTERNAL BLADDER 443 ❑ 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHERS 444 cif SECONDARY CONTAINMENT ❑ L STEEL . FIBERGLASS C16. EXTERIOR MEMBRANE LINER ❑ Z SACKETED 444. 445 ❑ 90. NONE ❑ 95.UNKNOWN ❑99. OTHER S a' : OVERFILL PREVENTION . AUDIBLE A VISUAL ALARMS 2. BALL FLOAT 3. FILL TUBE SHUT-OFF VALVE 443a 452. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT a. ..4.r PIPING CONSTRUCTION 1. SINGLE.WALLED 2. DOUBLE-WALLED ❑ 99.OTNEA SYSTEM❑ TYPE ❑ 1. PRESSURE ❑ 2. GRAVTTV ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION 23 CCR 2636(a%]) 460 459 PRIMARY PRIMARY CONTAMMEM L STEEL /.FIBERGLASS ❑ e. FLE#BLE ❑ 10. RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Speeily): SECONDARY CONTAINMENT ❑ 1. STEEL 4. FIBERGLASS ❑ 8. FLE#BLE ❑ 10. RICID PLASTIC 464. 464b (] 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHFJt (S eeify): 464 PIPMGRURBME CONTAINMBNi SUMP TYPE ❑ I.SMGLE WALL E2DOUBLE WALL 90.NONE 464d VENT PRIMARY CONTAINMENT Q 1. STEEL 6. FIBERGLASS 10. RIGID PLASTIC 90. NONE 99.OTHER (Speafy) 464a VENT SECONDARY CONTAINMENT_I.STEEL -.FIBERGLASS IO. RIGID PLASTIC 90. NONE 99.OTHER (Specify) v fy) 4 464, VR PRIMARY CONTAINMENT ,STEEL .FIBERGLASS 10: RIGID PLASTIC 90. NONE El 99. OTHER (Specify) 4&I 464, VR SECONDARY GONTAMMENT U LSTEEL .-FIBERGLASS10. RIGIDFUTTIC 90.N0NE 99.OTHER (Specify)4464h VENT PMTRANSITION SUMP TYPE L SINGLE WALL NE 4446h4il RISERFUM., CUNMINMT .10. RICID PLASTIC 90. NONE 99. OTHER (Specify) . 464j RISER SECONDARY CONTAINMENb I U 4. FIBERGLASS U 10. RIGID PLASTIC 90.NONE 99. OTHER (Specify) 641 464k FILL COMPONENTS INSTALLED ' .SPILL BUCKET 1. STRIKER PLATE/BOTfOM PROTECTOR 4. CONTAINMENT SUMP Osla-e CONSTRUCTION TYPE ❑ LSWGLE WALL �.LDOUBLE WALL ❑ 3. NO DISPENSERSry ❑ 90. NONE 46% CONSTRUCTION MATERIAL 1. STEEL 4. FIBERGLASS x'10. RIGIp PLASTIC ❑ 99.OTHER S eci 469b.c .... _ STEEL COMPONENT PROTECTION ❑ 25ACRIFICLLL ANODES) ❑ I. IMPRESSED CURRENT 6. ISOLATION 449. CERTIFICATION: I certify that thb UST system U compatl6le with the hazardOm substance stored and that the Information provided herein Is Vee, accurate, and In full comg&nce with legal requirements. APPLICANT SIGNATURE DATE 470. APPLICANT NAME (print) 471' APPLICANT T) E 472. A4A% UPCF UST -B -1/2' Rev. (128007)