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..,, UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per LIST) TYPE OF ACTION (Check one item only. For ao UST permanent closure or removal,complete only this section and Sections I,II,IB,N,and IX below) 430 .NEW PERMIT ® 3.RENEWAL PERMIT ET5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL 4306 DATE UST PERMANENTLY CLOSED: 430° DATE EXISTING UST DISCOVERED: I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) - - - U (] 4 S 1 3 BUSINESS NAME(Same as FACILITY NAME or DBA-Doin Business As) BUSINESS SI �DTFV, R h 7(-24 NEit e p O/q- I103CITY L/OD, CA- 1! / U.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 .A STAND-ALONE TANK T112vt,V- ' rA��-t-e. [12.ONE IN A COMPARTMENTED UNIT. Cam tem one e%r each mm comenf in the unit. DATE UST SJSTEIy INSTALLED 435 TANK CAPACITY IN GA�. NUMBER 436 UMBER OF COMPARTME S E UNIT 437 (-lb-q4 . ono �A�- l�2 �% III.TANK USE'AND CONTENTS TANK USE a.MOTOR VEHICLE FUELING ❑ Ib.MARINAFUELING ❑ 1..AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Include Uud Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC¢352865(c)) ❑ 6.OTHERGENERATORFUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439. CONTENTS PETROLEUM: a.REGULAR UNLEADED [Ile.MIDGRADE UNLEADED [IIb.PREMIUMUNLEADED 440 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): s4h NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUMS ci ): NOb V. TANK CONSTRUCTION TYPE OF TANK ❑ 1 INGLE WALL .DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT 0FL STEEL ❑ J.FIBERGLASS ❑ 6.INTERNAL BLADDER d14 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTBER (Specify): 4/4a SECONDARY CONTAINMENT ❑ L STEEL LV3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN 1 [199.OTHER 5 "U OVERFILL PREVENTION ❑ 1.AUDIBLE&.VISUAL ALARMS 2.13ALLFLOAT .FILL TUBE SHUT-0FF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODU T/.WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 131.SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE .PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(.)(3)1 458 PRIMARY CONTAINMENT ❑ L STEEL Vr4.FIBERGLASS ❑ S.FLEXIBLE ❑ UL RIGID PLASTIC 464 ❑ 90.NONE ❑ 95 OWN ❑ 99.0'fHER(Specify): 464° SECONDARY CONTAINMENT ❑ L STEEL .FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 9o.NONE ❑ 9 UNKNOWN ❑ 99.OTHER(Speuity): 46da PIPING(TURBINE CONTAINMENT SUMP TYPE Uri.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE a64d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL :FIBERGLASS ❑ [0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4&1 464e1 VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) a64f d69B VR PRIMARY CONTAINMENT L STEEL .FIBERGLASS 10.RIGID PLASTIC D 90.NONE 0 99.OTHER(Specify) 4646 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL 13 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 4646 464hl VENT PIPING TRANSITION SUMP TYPE J,SINGLE WALL M 2.DOUBLE WALL ❑ 90.NONE 4641. RISER PRIMARY CONTAINMENT L14 L STEEL ❑ 4.FIRFRGLASS U HI RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Spaafy) 4641 4641 RISER SECONDARY CONTAINMENT ❑ 1.sTlim, 13 1.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED W.SPILLBUCKET ❑ 3.STRIKER PLATE/BOTI OM PROTECTOR ❑ 4.CONTAINMENT SUMP 451. .UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE GLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469. CONSTRUCTION MATERIAL V&LSTFEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4691.c VIII. CORROSION PROTECTION _STEEL COMPONENT PROTECTION :12.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 493' LY. 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 com Lance with legal re uir ments. APPLI IGNATURE 470.DATE Q 2 ler APPLICANT NAME c(e�nnt) d71' APPLICANT TITLE 472. /1 EE+l/ S• �/Z S Cd/ UPCF UST-B-1/2 Rev.(12/2007)