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1 UNIFIED PROGRAM CONSOLIDATED Fsa 4 � UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION 2LUOtLO TYPE OF ACTION (Check one item only. Foran UST permanent closure or removal,complete only this section and Sections 1.H.III,IV,and IX below) 930 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: 430e DATE EXISTING UST DISCOVERED: 4306 L FACILITY INFORMATION -7 FACILITY ID#(Agency Use Only) - BUSINESS NAME(Same LITY NAME or A-Doing Burin ) !/ 3 BUSINESS SITE ADDRESS 'rl 1 _Ip CITY ) X00 CgWfV ~ TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 I.ASTAND-ALONE TANK f 71)fA/// //❑2.ONE M A COMPARTMENTED UNIT. - - - - -- IN �N"� G Ore ove efareerh com iv arc w"v. --- ATE UST SYS ED 435 TANK C LONS 436 NUMBER OF COMPARTMENTS M THE UNIT 437 III.TANK USE AND CONTENTS TANK USE ❑ is.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE -jjC4.HAZARDOUS WASTE(Ivcludn USW Oil) ❑ 5.EMERGENCY GENERATOR FUEL[RSC W281.5(c) ❑ 6.OTHER GENERATOR FUEL /0 95.UNKNOWN ❑ 99.OTHER (Specify): 439. CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM.' .USED OI. ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL K 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT I-STEEL ❑ 3_FIBERGLASS ❑ 6.INTERNAL BLADDER Ya44 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99 OTHER (S i ): aa4e SECONDARY CONTAINMENT Ar 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify) 445. OVERFILL PREVENTION L 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 151.SINGLE-WALLED [12.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE .PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR g2636(a(3)) 458 PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): a6aa SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4MI, -EFW NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGITURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL -I$ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT r7 '.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ %NONE 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT 0 L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC A 90.NONE 0 99.OTHER(Specify) 464f 4Mfl VR PRIMARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464g 464 1 VR SECONDARY CONTAINMENT 0 L STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464h 469h1 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE abai RISER PRIMARY CONTAINMENT SU L STEEL U 4.FIBERGLASS ❑ ]0.RIGID PLASTIC 90.NONE U 99.OTHER(Speciy) 464i 464'1 RISER SECONDARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464k 4641,1 FILL COMPONENTS INSTALLED 0 1.SPILL BUCKET ❑ 3.STRIKER PLATUBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451.c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOABLE WALL ❑ 3.NO DISPENSERS >0790.NONE 469. CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bo VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION a8. 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 fuB compliance with legal requirements. APPLICANT SIGNATURE DATE 470' APPLICANT NAME(print) 411' APPLICANT TITLE 472. UPCF UST-B-1/2 Rev.(12/2007)