BILLING - Laserfiche WebLink

Home Browse Search

z3zo 11 UNIFIED PROGRAM CONSOLIDATED% ' UNDERGROUND STORAGE TANK I2� OPERATING PERMIT APPLICATION-TANK INFORMATION(one LIP OSTj .TNXE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,II,III,IV,and IX below) 430 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION Lj 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: °3,a DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) - _ _g BUSINESS NAME(Same as FAQLITY NAME or D - in Business As � U� 3 BUSINESS SITE ADDRESS I ('(Io3 CITY I0/ II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: TRIS TANK IS 434 �%� N I.ASTAND-ALONE TANK D __ _ _ ` tJ✓f I/ ❑2.ONE IN A COMPARTMENTED UNIT. - Co la<orc eforeech mm meal iv a,e,md: DATE UST SYSTEM INST� 435 TANK CtIff5y INGALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 III.TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(l id U d W) Q 5.EMERGENCY GENERATOR FUEL[RSC§25281.5(c)l ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN .OTHER (Specify): 43% CONTENT'S PETROLEUM: ❑ la.REGULAR UNLEADED 0 lc.MIDGRADE UNLEADED 0 Ib.PREMIUM UNLEADED 440 O 3.DIESEL ❑ 5.JET FUEL Q 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL V9.OTHER PETROLEUM (Specify): 'D Oe NON-PETROLEUM:❑ 7.USED OIL LF10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): a4ob IV. TANK CONSTRUCTION TYPE OFTANK O 1.SINGLE WALL V 2.DOUBLE WALL ❑ 95.UNKNOWN a3 PRIMARY CONTAINMENT L STEEL (] 3.FIBERGLASS ❑ 6.INTERNAL BLADDERya 444 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (specify): a44e SECONDARY CONTAINMENT X 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED a5 ❑ 90.NONE El 95.UNKNOWN ❑99.OTHER(S i ): 445° OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS U 2.BALL FLOAT b 3.FILL TUBE SHUT-OFF VALVE 452. 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 1.SINGLE-WALLED W.DOUBLE-WALLED O 99.OTHER 460 SYSTEM TYPE 1.PRESSURE LI 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION In CCR§1636(.)(3)1 458 PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS-(:18.FLEXIBLE O 10.RIGID PLASTIC 464 O 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specf ): 464e SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS D 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 19 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Speei PIPING/I'URBINE CONTAINMENT UMP TYPE Q 1.SINGLE WALL ❑ Z DOUBLE WALL 90.NONE 4644 VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL U 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464° 464e1 VENT SECONDARY CONTAINMENT EI L STEEL 4.FIBERGLASS O 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 9Nt 4648 VR PRIMARY CONTAINMENT D 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE C 99.OTHER(Specify) 4648 VR SECONDARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464b 464hl VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 464i RISER PRIMARY CONTAD41VMNT ❑ 1.STEEL 0 4.FIBERGLASS (] 10.RIGID PLASTIC A5 90.NONE U 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS O 10.RtG1D PLASTIC 90.NONE 0 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLAT&BOTTOM PROTECTOR 4.CONTAINMENT SOW 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE O 1.SINGLE WALL ❑ 2 DOUBLE WALL ❑ 3.NO DISPENSERS 90.NONE 469° CONSTRUCTION MATERIAL L] 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC O 99.OTHER(Specify) 4696-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION O 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. 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) 41. APPLICANTTITLE 471. UPCF UST-B-1/2 Rev.(12/2007)