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0 UNIFIED PROGRAM CONSOLIDATED FORM 1 UNDERGROUND STORAGE TANKF� OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) PE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,11,III,IV,and IX below) 430 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: 430a DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION. FACILITY ID#(Agency Use Only) tz_O _ D _ l BUSINASS NAME(Same as FAC TY NAME or DBA-Doing Business As) 3 BUSINESS SITE ADDRESS J ` /� ,may 103 CITY n -� ` 104 Y II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433ra ONFIGURATION:THIS TANK IS 434 l.A STAND-ALONE TANK �.ONE IN A COMPARTMENTED UNIT. Complete one page for each omnimmmu in the mvl. DATE UST SY TEM INSTALLED 435 TANK CITY IN GALLONS 436 NUMBER OFCOMPARTMENTS IN THE UNIT 437 - V M.17AAk USE AND CONTENTS TANK USE a.MOTOR VEHICLE FUELING [I Ib.MARINA FUELING [IIc.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: s.REGULAR UNLEADED ❑ 1 c.MIDGRADE UNLEADED I b.PREMIUM UNLEADED 440 3.DIESEL [15.JET FUEL 6.AVIATION GAS PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM.❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+►NTE INING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE 95.UNKNO ❑99.OTHER(S ec' ): 445a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. [14.TANK MEETS REQUIREMENTS R EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 1.SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(ax3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ &FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ I.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND SER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL4.FIBERGLASS El10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ I0.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 0-99.OTHER(Specify) 4648 4640 VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE 0 1.SINGLE A L .DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT I.STEEL . 4.FIBERGLAS Ij 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4641 464'1 RISER SECONDARY CONTAINMENTSTEEL 1@04 FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED WJ.SPILLBUCKET 3.STRIKER PLATEMOTTOM PROTECTOR . 4.CONTAINMENT SUMP 451a VII.UND DISPENSER CONTAINMENT CONSTRUCTION TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 4698 CONSTRUCTION MATERIAL ❑ 1.STEEL .FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b< 'VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION:I certify the US ystem Is compatible with the hazardous substance st ed and that the information provided herein is true,accurate, and in full m h ce i t al requirements. APPLICANT SIGN DATE v i 1 470' APPLICANT`S NAI)4A((print 471' APPLICANT TITLE, 4r. UPCF UST-B-1/2 Rev.(12/2007)