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Z3 2z 1( y�NIFIED PROGRAM CONSOLIDATED F,,au14 1 ul r� Z I UNDERGROUND STORAGE TANK * y�� OPERATING PERMIT APPLICATION-TANK INFORMATION(tJne fowl der u�T) I E OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,II,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 ATE UST PERMANENTLY CLOSED: 4308I DATE EXISTING UST DISCOVERED: °ion I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) q - 10 1 D 10 1 - Z BUSINESS NAME(Samer , N E or DB 'ng Business AS 3 BUSINESS SITE ADDRESS A IU3 C1TY ' l04 II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: TBISTANKIS 434 I.A STAND-ALONE TANK JD 2.ONE IN A COMPARTMENTED UNIT. Co Meove brexh com mem iv�6euoh. ATE US S M 1MV0 435 TANK CAPA GALLONS 436 NUMBER OF COMPARTMENTS M THE UNIT 437 III.TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ 16.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(hcludm Us On ❑ 5.EMERGENCY GENERATOR FUEL[NSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN jjjr99.OTHER (Specify): 439. CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 03.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS 140 ❑ 8.PETROLEUM BLEND FUEL .DTIBiR PEIROLEIIM (S i ): 440e NON-PETROLEUM:❑ 7.USED OIL 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ru 2.DOUBLE WALL ❑ 95.UNKNOWN u3 PRIMARY CONTAINMENT .STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER F7444 .STEEL, LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): ): 8448 SECONDARY CONTAINMENT 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445. OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION .SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR§2636(.X3)] 458 PRIMARY CONTAINMENT pn.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(S ify): 464. SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS8.FLEXIBLE [110.RIGID PLASTIC 464b 90.NONE [195.UNKNOWN 99.OTHEIS ify): a64c PIPINGFFURBINE CONTAINMENT P TYPE LJ L SINGLE WALL 2.DOUBLE WALL 90.NONE 4614 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FELL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) a64r 464h VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 4648 46491 VR SECONDARY CONTAINMENT L STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464h 464h1 VENT PIING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL E3 2.DOUBLE WALL 90.NONE 4641. RISER PRIJOARY CONTAINMENT ❑ L STEEL 0 4.FIBERGLASS U I0.RIGID PLASTIC90.NONE Ll99.OTHER(Specify) 469j 464'1 RISER SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464e 46411 FILL COMPONENTS INSTALLED 1.SILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR 0 4 CONTAINMENT SUMP 451.-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS IN 90.NONE 4698 CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 848. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hamrdous 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' APPLICANT TITLE 472- UPCF UST-B-1/2 Rev.(12/2007)