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UNIFIED PROGRAM CONSOLIDATED FORM I UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) FOR TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,1I,III,IV,and IX below) 430 ElL NEW PERMIT ❑ 3.RENEWAL PERMIT E3 5.CHANGE OF INFORMATION [] 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: "0a I DATE EXISTING UST DISCOVERED: 430b FACILITY ID#(Agency Use Only) FACILITY INFORMATION J _ : 1 71 BUSINESS NAME(Same as FACILITY NAME or DSA-Doing Business As) 3 A1121-4,6, BUSINESS SYM ADDRES9 CITY 104 II.TANK DESCRIPTION TANK lD# 432 TANK MANUFACTURER. 433 TANK CONFIGURATION:THIS TANK IS 434 VS-0I, rJ//S r) 19 1.A STAND-ALONE TANK T /Z t 0 [12.ONE IN A COMPARTMENTED UNIT. DATE US SYS2M INSTALLED 435 Com ete one for each wm Ud in the urk TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 12 •Lfi L�tS III.TANK USE AND CONTENT_ S TANK USE ® la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ la AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used(lit) [3 5.EMERGENCY GENERATOR FUEL[HSC¢25281,5(c)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: X I a.REGULAR UNLEADED ❑ 1 c.MIDGRADE UNLEADED ❑ I b.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6,AVIATION GAS ❑ S.PETROLEUM BLEND FUEL Q 9,OTHER PETROLEUM (S 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 1 I.OTHER NON-PETROLEUMS i ): 446b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL ❑ 3.FIBERGLASS C] 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.00THER (specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL X 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LEVER ❑ 7.JACKETED 445 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S ): 445. 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 I WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION Q 1.SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVrfY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(ax3)] 456 PRIMARY CONTAINMENT ❑ 1.STEEL W4.FIBERGLASS ❑ a.FLEXIBLE ❑ I0.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4646 SECONDARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS ❑ S.FLEXIBLE ❑ I0.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGtrutBINE CONTAINMENT SUMP TYPE L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464A VI:VENT,VAPOR RECOVERY(VR)"AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464c VENT SECONDARY CONTAINMENT 464e1 I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC tom•90.NONE ❑ 99.OTHER(Specify) 464! VR PRIMARY CONTAINMENT1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 464f] ❑ 90.NONE ❑ 99.DTHER(Specify) 464g VR SECONDARY CONTAINMENT464 1 ❑ f.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC �,NONE ❑ 44.OTHER(Specify) 4641 VENT PIPING TRANSITION SUMP TYPE 'I.SINGLE WALL 2.DOUBLE WALL 90 NONE 46411 464L RISER PRIMARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464j RISER SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS U ]0.RIGID PLASTIC ot 90.NONE Ll 99.OTHER(Specify) 464k FILL COMPONENTS INSTALLED 464k1 SPILL BUCKET 3.STRIKER PLATFIBOTTOM PROTECTOR 4.CONTAINMENT SUMP 4SIa c VII.UNDER DISPENSER CONTAINMENT,(UDC). CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL [13.NO DISPENSERS ❑ 90,NONE 469. CONSTRUCTION MATERIAL 1.STEEL ❑ 4.FIBERGLASS ❑ ]0.RIGID PLASTIC ❑ 99.OTHER(S i ) 469b 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 cam Bance with legal requirements. APPLICANTSIGNA7` '/ DATE 470, r APPLICANT NAME(prin- 471. APPLICANT TITLE 4n_. ('f l ". t-( IV c>rX/lY R- UPCF UST-B-1/2 Rev.(1212007)