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0 0(0 c y 2- _rF UNIFIED PROGRAM CONSOLIDATED FOI_.t UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) \ TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,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 Ej 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430' 1 DATE EXISTING UST DISCOVERED: 430b 13 L FACILITY'INFORMATION FACILITY ID#(Agency Use Only) _ _ 1 BUSINESS NAMS}a�me"as F' MEACII,ITY NA1p[),V�,B✓IA-Doing Business As) 3 BUSINESS SITE ADDRESS 103 1 CITY 104 II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS -/� t) 1 2�( !r 7 •1.A STAND-ALONE TANK , 01 L U fes, f�LJ 2.ONE IN A COMPARTMENTED UNIT. I T ConTpietc one page for each compvmu t in the,mil. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMB PARTMENTS IN THE UNIT 7 °1.... u III.TANK USE AND CONTENTS TANK USE IJZL la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ ]c.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oip ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(.)] [16.OTHER GENERATOR FUEL [__195.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: la.REGULAR UNLEADED El !c.MIDGRADE UNLEADED [3Ib.PREMIUM UNLEADED 440 3.DIESEL [15.JET FUEL [16.AVIATION GAS .PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM $ 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4411 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+NTERNA-r INTERNA-rLINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL t FIBERGLASS El 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 90.NONE 95.UNKNOWN , C]99.OTHER(Specify): 445a OVERFILL PREVENTION .AUDIBLE&VISUAL ALARMS ALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. Ll 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR§2636(ax3)] 458 PRIMARY CONTAINMENT 0 1.STEELFIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 El 90.NONE 5.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE 0 95.UNKNOWN Q 99.OTHER(Specify): 464c PIPING[URBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND kISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT EII.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE C 99.OTHER(Specify) 464e 464.1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 10.RIGIDPLASTIC ❑ 90.NONE El 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS U 10.RIGID PLASTICx'90.NONE ❑ 99.OTHER(Specify) 4648 �P �:' 464g] VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS 0 10.RIGIDPLASTIC ' 0.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 464i. RISER PRIMARY CONTAINMENT 1.STEEL U 4.FIBERGLASS U 10.RIGID PLASTIC NONE 0 99.OTHER(Specify) 464j 464'I RISER SECONDARY CONTAINMENT 1.STEEL M 4.FIBERGLASS El 10.RIGIDPLASTIC9464k1 0.NONE 99.OTHER(Specify) 464k FILL COMPONENTS INSTALLED I.SPILL BUCKET 3.STRIKER PLATF/BOTTOM PROTECTOR ' .CONTAINMENT SUMP 451a-c VII..UNDER DISPENSER CONTAINMENT'(LTi1C) CONSTRUCTION TYPE ❑ 1.SINGLE WALL 2fQ.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 99.OTHER(Specify) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT --,fig-6.]SOLATION 448 IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST sFstem is compatible with the hazardous substance stored and that the information provided berein is true,accurate, and in full compliance vii0letzal re uirements. APPLICANL�GNA'IURE' M DATE ; ( � 420. 1J �' APPLICANT N�(pn ) �� 471' APPLICANT TITLE 47'- 1 , C" UPCF UST-B-1/2 Rev.(12/2007)