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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) jTE OF ACTION (Check one item only. Foran UST pemlaneat closure or removal,complete only this section and Sections I,H,IH,IV,and IX below) 430 J I.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ S.UST REMOVAL r DATE UST PERMANENTLY CLOSED: 6J0i DATE EXISTINGUST DISCOVERED: eb I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) Y _ G _ G O f' `S 1 BUSINESS NAME(Same as FA��nNA�riF,or DB`A7-D oing Business As r 3 aus Ess .J ADDRESS EA 12.00, ��J a3 cITY�L�% IN �/I II.TANK DESCRIPTION TANffK��ID# 432 TANK MANUFACTURER � d33 TANK CONFIGURATION: THIS TANK IS 434 T vS�O77�IVJ� .=7UC- ASTAND-ALONE TANK 2.ONE MA C%=hM.1 -1,UNIT. Com ne one a efreach M..1 nmcnt in We coir. DATE UST SYSTEM INSTALLED 433 TAN APACITY IN GALLONS 436 NUMBER Oji C/O'MPA�1'ME IN THE UNIT 432 I( J R$ c9da 4 �- j A1,16 1.1 C 2 M.TANK USE AND CONTENTS TANK USE 1 a.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(i.d du U.ed Oil) ❑ 5.EMERGENCY GENERATOR FUEL(HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN P 99.OTHER (Specify): 439. CONTENTS PETROLEUM: ❑ is.REGULAR UNLEADED ❑ le.MIDGRADE UNLEADED Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ .AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 44M NON-PETROLEUM:[]'7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(S ci : 4 b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1. CLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT .STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNALL G ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444. SECONDARY CONTAINMENT ❑ 1.STEEL IBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN 99.OTHF1i(S i MSa OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS .BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODU /WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ INGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a 3)1 458 PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONEEl 95.uNKNowN [199.OTHER(Specify): 4641% SECONDARY CONTAINMENT [31.STEEL 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGIDPLASTIC 4646 ❑ 90.NONE ❑ 95 OWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE .SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 46id VI.VENT,VAPOR RECOVERY )AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464,,lVENT SECONDARY CONTAINMENT ❑ 1.STEEL 114. IBERGLASS [I 10.RIGID PLASTIC 9O.NONE ❑ 99.OTHER(Specify) 46Q 464Fl VR PRIMARY CONTAINMENT' 1.STEEL 4.FIBERGLASS El 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 464g 464 1 VR SECONDARY CONTAINMENT El 1.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC9 NONE ❑ 99.OTHER(Specify) 1646 6461 VENT PIPING 7RANSTDON SUMP TYPE ❑ 1 GLE WALL _ 2.DOUBLE WALL 90.NONE 464i. RISER ZMARY CONTAINMENT .STEEL I, t LYBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) a64) 464'1 RISER SECONDARY CONTAINMENT ❑ 1. r.FIBERGLASS 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Spuify) 464k 464kl FILL COMPONENTS INSTALLED I.SPILLBUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451. .UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE UAI-NG LE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL LrLSTEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4 IMPRESSED CURRENT ❑ 6.ISOLATION 448. 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 full compliance with legal requirements APPLIC IGNATURE DATE400. APPLICANT NAME(print) /� G d01' APPLICANT TITLE n an. -061/7EEN S l/ f y B ✓NEn /'I1ES/®GSI UPCF UST-B-1/2 Rev.(12/2007)