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200 C(� UNIFIED PROGRAM CONSOLIDATED FORM \)' ' UNDERGROUND STORAGE TANK k t/ (' 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 1,II,III,IV,and IX below) 430 NEW PERMIT ® 3.RENEWAL PERMIT El5.CHANGE OF INFORMATION 2 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL /1 DATE UST PERMANENTLY CLOSED: 430` DATE EXISTING UST DISCOVERED: 4 : :I:-FACILITY:INFORMATION. FACILITY ID#(Agency Use Only) ZPUI" BUSKS NAME(Same as FACHA7 NAME or DBA-Doing Business As) 3 i� PTYN 1 'ori BUSINESS SITE ADDRESSCITY 104 103 H.TANK DESCRIPTION ] TANK ID# / 432 TANK MANUFACTURER 433 TA ONFIGUAATION:THIS TANK IS 4S 61 (� * J �I � 1.A STAND-ALONE TANK Lb/✓-1 '� ��'T J{?�-� ONE IN A COMPAR'(TgNTED UNIT. Complete one a for each art in the tadt. DATE UST SY TEM INSTALLED 435 TANK C ITY IN GALLONS 436 NUMBER OFCOMPARTMENTS IN THE UNIT 437 M.1rARk USE AND CONTENTS TANK USE Q la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Ic.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Inchdes 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 lb.PREMIUM UNLEADED 440 3.DIESEL ❑ 5.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+INTER INtNG ❑ 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 I.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT D 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS YOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑I.SINGLE-WALLED M 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(aH3)] 458 PRIMARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGITURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND MSER/.FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT El 1.STEEL4.FIBERGLASS 0 ]0.RIGID PLASTIC 90.NONE El99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL J?L 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641' 464n VR PRIMARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ l0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464g) VR SECONDARY CONTAINMENT ❑ L STEEL j!Z:4-FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE ALL DOUBLE WALL 90.NONE 464i. RISER PRIMARY CONTAINMENT 1.STEEL _ 4.FIBERGLASS 10.RIGIDPLASTIC 90.NONE 99.OTHER(Specify) 4641 464'1 RISER SECONDARY CONTAINMENT STEEL FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED .SPILL BUCKET 3.STRIKER PLATEBOTTOM PROTECTOR JFL 4.CONTAINMENT SUMP 45la-c VII.ITND ISPENSER CONTAINMENT CONSTRUCTION TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ I.STEEL FIBERGLASS ❑ 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 thaphkUST ystem is compatible with the hazardous substance stgred and that the information provided herein is true,accurate, and in full m hce l4legal al re uirements. APPLICANT SIGNATURE DATE \ 470. APPLICANT NAn(print 411' APPLICANT TITLE:, J� 472. UPCF UST-B-1/2 Rev.(12/2007)