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IFIED PROGRAM CONSOLIDATED F(.,.0 UNDERGROUND STORAGE TANK 1L"0 I �) OPERATING PERMIT APPLICATION-TANK INFORMATIOP!(One foh k VT� PE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,Ili,IV,and IX below) 430 I.NEW PERMIT ® 3.RENEWAL PERMIT ❑ S.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 43OeI DATE EXISTING UST DISCOVERED: 4301E I. FACILITY INFORMATION 1 FACILITY ID#(Agency Use Only) 1,41 K9 BUSINESS N S FAWWBA-Dgmg Business As) 3 0724 A, caw BUSINESS SITE ADDRESV 103 1 CITY 104 N II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433T69k CONFIGURATION: THIS TANK IS 434 tEl L A STAND-ALONE TANK qqg4/L j � ❑2.ONE IN A COMPARTMENTED UNIT. !! Co Ineone eforexhwm crawneunit. DATE UST SYSTE ED 435 TANK CA ACITY NS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 III.TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(l Jud.Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25291.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MEDGRADE UNLEADED lb.PREMIUM UNLEADhD 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATIOIJ)GpS 4 q, I ❑ B.PETROLEUM BLEND FUEL .OTHER PETROLEUM (S i ): �(�� V I 44)a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 444)6 IV, TANK CONSTRUCTION TYPEOFTANK ❑ I.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL,INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER S ify): 444a SECONDARY CONTAINMENT1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. .TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION .SINGLE-WALLED ❑2.DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE .PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(AX3)] 458 PRIMARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS ❑ &FLEXIBLE ❑ 10.RIGIDPLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Spccifyy 4644) SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT MP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4644) 4644)1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464f 4641 VR PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC rg 90.NONE ❑ 99.OTHER(Specify) 464g 464 I VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SLUMP TYPE 1.SINGLE WALL [12.DOUBLE WALL 90.NONE 464L RISER PRIMARY CONTAINMENT L STEEL U 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 4641 464'1 RISER SECONDARY CONTAINMENT 0 L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC Iff 90.NONE 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED ❑ L SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS .NONE 469a CONSTRUCTION MATERIAL ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696 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) 071 APPLICANTTITLE 472_ UPCF UST-B-1/2 Rev.(12/2007)