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1C�of UNIFIED PROGRAM CONSOLIDATED FORM I 3 UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATI ne form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,II,III,IV,and IX below) 430 X_1.NEW PERMIT [13.RENEWAL PERMIT [15.CHANGE OF INFORMATIO 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL o� DATE UST PERMANENTLY CLOSED: 430a I DATE EXISTING UST DISCOVERED: d1o1i I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) O _ _ S BUSINESS NAME( am sGACILITY AME or D -Doin Business As 3 od fIA4 13 3 I! S SIT DD $Q G O 103 CITY -T/? o 104 J 1 -- ll.TANK DESCRIPTION TANK ID# 432 'I ANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 ` ' e r�� ❑1 A STAND-ALONE TANK lV�, ��L/2 ONE IN A COMPARTMENTED UNIT. Com lete one page for each compartment in the unit. DATE UST SYSTEM I STALLED 435 TANK C PACIT IN GALLONS 436 NUMBER OF COMPA' 1000 � MEN'I'S IN THE UNIT 437 III.TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING [:1 lb.MARINA FUELING ElIc.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE [14.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: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED 1b.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 2,DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL 14 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTIIER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL �3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 El 90.NONE 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION I.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT [13.FILL TUBE SHUT-OFF VALVE 452- 4.TANK MEETS REQUIREMENTS FOP EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE [12.GRAVITY [13.CONVENTIONAL SUCTION [14.SAFE SUCTION[23 CCR§2636(a)(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 PIPINGITURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL 36L 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL $F4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 464fl VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464s 4641 VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 46411 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 4641. RISER PRIMARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 4641 RISER SECONDARY CONTAINMENT ❑ 1.STEEL 19 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464kl FILL COMPONENTS INSTALLED 1.SPILL BUCKET W 3.STRIKER PLATE/BOTTOM PROTECTOR K 4.CONTAINMENT SUMP 451 a-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL IV 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL X 4.FIBERGLASS El 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448. 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, and in full compliance with legal requirements. APPLICANT SIGNATURE DATE 470. APPLICANT NAME(print) 471. APPLICANT TITLE 472, UPCF UST-13-1/2 Rev.(12/2007)