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),,,IFIED PROGRAM CONSOLIDATED FCawi (� UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one fo m per`u�� 0 E OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,Il,III,IV,and IX below) 430 1.NEW PERMIT ® 3.RENEWAL PERMIT C] 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE C] 7.UST PERMANENT CIASURE ON SITE E] 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430e DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use OnJP) _ - 3 1 BUSINESS NAME(S C NAME or B -Dein Business e4��y 3 BUSINESS SITE ADDRESS L44103 I CITY 10° II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 CONFIGURATION: THIS TANK IS 030 1.A STAND-ALONE TANK ❑2.ONE IN A COMPARTMENTED UNIT. Co lac om Emetor each compamnenImthe unk. D TE UST S ST*kKLLED 435 TANK CAPACITY ALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 43'7 III.TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑d1b.MARINA FUELING C] Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE §p..4.HAZARDOUS WASTE(i.td UaeitTl) ❑ 5.EMERGENCY GENERATOR FUEL(HSC§252s1.5(c)] C16.OTHER GENERATOR FUEL /❑ 95.UNKNOWN ❑ 99.OTHER (Specify): Aga CONTENTS PETROLEUM: ❑ 1a REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 400 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (specify): d4Oe NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL -Q (Specify) 1.OTHER NON-PETROLEUM if): wiwT. 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ L SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ L STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER �j t 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN99.OTHER (Specify). / 4+I 4441 SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR ME BRINE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN99.OTHER(Spec ): We OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2. FLOAT ❑ 3.FILL TUBE SRUT-0FF VALVE 452, 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 1.SINGLE-WALLED 2.DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE ❑ I.PRESSURE JX 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(1X3)] 458 PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(S ify): 4641 SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PRPTNG/TURBINE CONTAINMENT SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 46'1 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) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC a 90.NONE ❑ 99.OTHER(Specify) 464( 464f1 VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC90.NONE ❑ 99.OTHER(Specify) 4646 tv 164 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE i.SINGLE WALL [12.DOUBLE WALL 90.NONE 4641 RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 4641464199.OTHER(Specify) 4641 4641 RISER SECONDARY CONTAINMENT ❑ I.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC90.NONE U 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a< VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS -90.NONE 469a CONSTRUCTION MATERIAL El 1.STEEL C34.FIBERGLASS [310.RIGID PLASTIC ❑ 99.OTHER(S city) 4696 VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION '149 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 I APPLICANT TITLE 472. UPCF UST-B-1/2 Rev.(1212007)