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UNIFIED PROGRAM CONSOLIDATED FORM 7F. UNDERGROUNDSTORAGETANKOPERATING PERMIT APPLICATION-TANK INFORMATION (OnTYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sect'wts/./(/!L!V,and l.Ybelow/ ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ONSITE LLL❑��8.UST REMOVAL DATE UST PER CLOSED: J3oa DATE EXISTING UST DISCOVERED:2!! 430b. I. FACILITY INFORMATION FACILITY ID#(Agencv Use Only) . -r-US[ SNAME(Samea c N llN mne ar BA- it Business As) 3. BUSINESS SITEt(OD?S 5 � nQ�(' �3 ' loJ. CITY loq. `_�,elC`' II.`/TTAANK DESCRIPTION TANK ID k +3'-- TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS +34. sog`3z 1.A STAND-ALONE TANK Completeane page for euh 2.ONE IN COMPARTMENTED UNIT pamnme In the unit DATE UST SYSTEM INSTALLED J36. TANK CAPACITY IN GALLONS aJ6. NUMBER OF COMPARTMENTS IN THE UNIT 437. tis CJ 2- III. III. TANK USE AND CONTENTS TANKUSE 1a.MGTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING JJ9. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Indmn Uxd Oil) ❑ 5.EMERGENCY GENERATOR FUEL IHSC¢'_5'_81.5(cp 0'6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER IS 439a CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440, DIESEL ❑ 5.)ET FUEL El6.AVIATION GAS PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify):: 440. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ------ --- ❑ 1I.OTHER NON-PETROLEUM IS ify): 4401a, IV. TANK CONSTRUCTION TYPE OF TANK _❑_I.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443, PRIMARY CONTAINMENT ❑ I.STEEL .FIBERGLASS ❑ 6.INTERNAL BLADDER 444. _ -_0 7_STEEL+INTERNAL LINING____❑ 95.UNKNOWN_❑ 99.OTHER(Speeify): a44a SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. Q 90.NONE 95.UNKNOWN _ 099.OTHER(Specify): 445a OVERFILL PREVENTION ❑ L AUDIBLE&VISUAL ALARMS ❑ ?.BALL ELOAT .FILL TUBE SHUT-OFF VALVE 453. El 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION __❑ 1_SINGLE WALL 2.DOUBLE WALL_ ❑_99.OTHER 46p SYSTEM TYPE .PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION 0_4.SAFE SUCTION 23 CCR§2636(.X31] 458. PRIMARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE -- 90.NONE 95.UNK_NOWN ❑ 10.RIGID PLASTIC J6J. - --- ❑ 99.OTHER 464. SECONDARYCONTAINMENT ❑ I.STEEL 1�'` L.I 4,FIBERGLASS ❑ 6.FLEXIBLE ❑ 10.RIGID PLASTIC JNb. 90.NONE 95.UNKNOWN----0 99.OTHER(Specify): 461. PIPING/TURBINE CONTAINMENT SUMP TYPE L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 461& VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT_ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): VENT SECONDARY CONTAINMENT -- ----- 46ie1. ❑ L STEEL -E4.FIBERGLASS ❑ 10.RIGH)PLASTIC 90.NONE ❑ 99.OTHER(Specify): 464F. VR PRIMARY CONTAINMENT LSTEEL +64n. _ _ ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4Ng VR SECONDARY CONTAINMENT - 46JeL _ _❑ I STEEL ❑ 4.FIBERGLASS ❑ 10.RICID PLASTIC 90.NONE ❑ 99.OTHER(Specify): +�h -- - ____ ____ -. 4Whl. VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL 490.NONE +66. RISER PRIMARY CONTAINMENT 1 STEEL ---- -- - --------- ------- -- ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90 NONE ❑ 99.OTHER(Specify): 464y RISER SECONDARY CONAINMENT ❑ I.STEEL )!F-4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46, 6+k. FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR +51 kI. ❑ 4.CONTAINMENT SUMP VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL __ _ _Q ?DOUBLE WALL ❑ 3.NO DISPENSERS 469. -__------ _ ❑ 90_NO_NE _ CONSTRUCTION MATERIAL L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT6.ISOLATION :4 +48. IX, APPLICANT SIGNATUREs CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided heFetn,}t true, accurate,a m lienee with le al irements. t APPLICANT SIGNATU DATE / O +7. APPLICANT NAME APPLICAN TITLE UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org !`