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IFIED PROGRAM CONSOLIDATED FW UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. For an UST pe mmenl closure or removal,complete only this section and Sections I,11,111,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 ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 9304I DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID 4(Agency Use Only) _ 1 BUSINESS NAME(Same as FACILITY NAME or DBA-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 434 ❑1.A STAND-ALONE TANK ❑2.ONE IN A COMPARTMENTED UNIT. Co let.ova pagefa,each compaMaad I.h.uv R. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 III.TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CREMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Iuclud.Uaed Oa) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25181.5(c)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN 0 99.OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED O Ic.MIDCRADE UNLEADED O Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL O 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (S i ): 490° NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUMS ci : 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 999 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444° SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 0 90.NONE O 95.UNKNOWN ❑99.OTHER(Specify): 4454 OVERFILL PREVENTION Lj 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT U 3.FILL TUBE SHUT-OFF VALVE 452. (] 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑I.SINGLE-WALLED ❑2.DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE ❑ F 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 ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4Mb ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGrrURBrNE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL C12.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4Mc 4M4 I VENTSECONDARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTFIER(Specify) 4Mf 4641 VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 964 I 464h1 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ I0.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Spmi6') 464h VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NO 46ML RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE O 99.UI HER(Specify) 4641 464'1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4Mk 464kl FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL 0 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIA. C11.STEEL ❑ 4.FIBERGLASS O 10.RIGIDPLASTIC ❑ 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 that this UST system is compatible with the hanrdous substance stored and that the information provided herein is true,accurate, and in full compliance with legal requirements. 470. APPLICANT SIGNATURE DATE APPLICANT NAME(print) 471' 1 APPLICANT TITLE c72. UPCF UST-11-1/2 Rev.(12/2007)