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2� UNIFIED PROGRAM CONSOLIDATED F�%aasMUNDERGROUND STORAGE 4/ �I�l c \ OPERATING PERMIT APPLICATION TAN INFORMATWIf OWN ne fo�m(`�er /]�t�si)UL TJ(PE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,11,III,IV,and IX below) 430 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ S.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE C] 8 8.UST REMOVAL ATE UST PERMANENTLY CLOSED: 411, 1 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) ^ _ D BUSINESS NAME(Sa LI NAME or -Doing Bus�neets /T 3 BUSINESS SITE ADDRESS ) �/ o CITY ioa CW" II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 CONFIGURATION: THIS TANK IS 434 s /K/ I A STAND-ALONE TANK ❑2.ONE IN A COMPARTMENTED UNIT. C ecce breach ie We un%. ATE U Y T D 435 TANK 17APAC ,GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 432 III.TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ ]c.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(ladudn Us Oil) ❑ 5.EMERGENCY GENERATOR FUEL[ASC§252SM(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN 0 99.OTHER (Specify): 43% CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MTDGRADE UNLEADED ❑ 16.PREMIUM UNLEADED 440 ❑ 3.DIESEL S.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL 9.OTHER PETROLEUM (specify): ✓YJ NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPEOFTANK ❑ 1.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 (specify): 444a SECONDARY CONTAINMENT 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S i ): a5e 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 L SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(03)1 453 PRIMARY CONTAIJMENT JB 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(S i ): 464a SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4wb 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 46/c PeINGI'IURBINE CONTAINMENT TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE awd VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) a64c 4we1 VENT SECONDARY CONTAINMENT U 1.STEEL U 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464( awn VR PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC Z W5,90.NONE ❑ 99.OTHER(Specify) 4w3 4w I VR SECONDARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC X 90.NONE ❑ 99.OTHER(Specify) 4wb 4Mh1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 4641, RISER PRIMARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464j 4w'1 RISER SECONDARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4wk 4Mki FILL COMPONENTS INSTALLED 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451.c VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS 90.NONE 469. CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION IX. APPLICANT APPLICANT SIGNATURE CERTIFICATION: 1 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) 411 APPLICANTTITLE 40'' UPCF UST-B-112 Rev.(1212007)