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UNIFIED PROGRAM CONSOLIDATED FORM l f n tl UNDERGROUND STORAGE TANK �7 OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,II,III,IV,and LX below) 430 PQil.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ S.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430aDATE EXISTING UST DISCOVERED: 'j-p p 4306 1. FACILITY INFORMATION FACILITY ID X(Agency Use Only) I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) /{ a 3 BUSINESS SITE ADDRESS103 CCTV loo it-715 tt + II.TANKDESCRIPTION TANK ID'# 432 TANK MANUFACTURER 433 TAA,�NI,CONFIGURATION: THIS TANK Is 434 �+� pay.A STAND-ALONE TANK Q Il y El 2.ONE M A COMPARTMENTED I MT. (1,P U Co ae one french com em in theum�. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 2,0 1 III.TANK USE AND CONTENTS TANK'�;S`c ❑ 1a..IIOTOR VtEICLE FUELING ❑ ih.NIARINAFUELING ❑ 1c.AVLATION FUELING '39 ' 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(induda Used 010 ❑ 5.EMERGENCY GENERATOR FUEL[HSC ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 43% CONTENTS PETROLEUM: ❑ Is.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL - ❑ 5.IEC FUEL ❑ 6.AVIATION GAS - --- -- ❑ 8.PETROLEUM BLEND FUEL 9.OTHER PETROLEUM (S eci ): to _ CP j 440. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL Cl 11.OTHER NON-PETROLEUM(Specify): 4406 IV.TANK CONSTRUCTION TYPE OF TANK J.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ I.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 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/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION Q71.SINGLE-WALLED ❑2.DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE ❑ I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR 42636(a)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464e PIPINGrrURBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464E VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING'CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Spwify) 464e 964c1 VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464r 46411' VR PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4645 4&1d VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 4601 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGL2.DOUBLE WALL 641 90.NONE 4 . RISER PRIMARY CONTAINMENT ❑ !.STEELE WALL C3 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464i 464'I RISER SECONDARY CONTAINMENT L STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 4Mk1 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR Cl 4.CONTAINMENT SUMP 451. VII.UNDER:DISPENSER'CONTAINMENT(UDC) Co:;; CTION TYPE ❑ L SINGLE WALL [1 '_ .,E WALL El 3.NO OISPCNSERS ❑ 90.N 469' CONSTRUCTION MATERIAL ❑ L STEEL C] 4.FIBERGLASS C1IQ RIGID PLASTIC ❑ 99.OTHER(Specify) 4696 VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 1q,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. APPLICANT SIGNATURE DATE 4N' APPLICANT NAME(print) 671' APPLICANT TITLE 412. UPCF UST-B-112 Rev.(12/200'!)