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�� lb I L UNIFIED PROGRAM CONSOLIDATED FORM _ UNDERGROUND STORAGE TANK IU 11\��C OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) E OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,R,III,IV,and IX below) 430 EW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ZJ 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4111, DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) n /{(10 s ^ _ 1010 1-1-L- _ 1 BUSINE $s NAME(SameFACILITY NAME AE or DBA-Doing Business As) 3 BUSINE9S SITE ADDRESS - 103 1 C i 104 II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 2cND-ALONE TANK � (' ""'� 2.ONE IN A COMPARTMENTED UNIT. Complete one page for each cmpmUnM in the writ. DATE UST ,WiSTALLED 435 TAS APACITY IN GALLONS 436 NUMBER O OM?ARTMENTS IN THE UNIT 437 � G III.TANK USE AND CONTENTS TANK USE �.MOTOR VEHICLE FUELING [I 1b.MARINA FUELING ElIc.AVIATION FUELING 439 L 13.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Inchdas Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6,OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHERS OTHER(Specify): 439a CONTENTS PETROLEUM: 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): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 99 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTE Al-LINING ❑ 95.UNKNOWN ❑ 99.OTHER (specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 90.NONE 95.UNKNOWN ❑99.OTHER(Specify) 445a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. 4.TANK MEETS REQUIREMENTS EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PROD CT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED .DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑4.SAFE SUCTION[23 CCR§2636(x)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.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 ❑ 1.SINGLE WALL .DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 1.STEEL19 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 46417 VR PRIMARY CONTAINMENT ❑ 1.STEEL 4. 464 1 FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS EJ 7W RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS 10.RIGID PI-ASTIC s 90.NONE 13 99.OTHER(Specify) 464k 464kl FILL COMPONENTS INSTALLED SPILL BUCKET jlr3.STRIKER PLATElBOTTOM PROTECTOR JIL4.CONTAINMENT SUMP 451a-c VII.UNDEA DISPENSEE CONTAINMENT CONSTRUCTION TYPE ❑ L SINGLE WAIL W,2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bt 'VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES) ❑4.IMPRESSED CURRENT 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION:I certify that this UST system is compatible with the hazardous substance stored and at the information provided herein is true,accurate, and in full cow lia c wi IeRal requilrements. APPLICANT SIGNATURE DATE 470. APPLIC NAME(print) �� 471. APPLICANT TITLE Q 472. UPCF UST-B-1/2 9- 1 '^-! '�'i:1 Rev.(1212007)