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IFIED PROGRAM CONSOLIDATED F <br /> UNDERGROUND STORAGE TANK F� S <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) 430 <br /> TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section 5. and Sections 1,11,111,IV,and IX IANGE OF INFORMATION below) <br /> ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT <br /> ® 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL 43ob <br /> DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: <br /> I. FACILITY INFORMATION <br /> rBUSINESS <br /> Y ID#(Agency Use Only) - <br /> 3 <br /> ESS NAME(Same as FACILITY NAME or DBA-Doing Business As) <br /> Gasoline o3 CTTv M <br /> SITE ADDRESS StOCIROn <br /> orth Wilson Wa <br /> U.TANK DESCRIPTION 434 <br /> TANK ID# 3 Unleaded 432 TANK MANUFACTURER 431 TANK CONFIGURATION: THIS TANK IS <br /> Modern Welding ®I.A STAND-ALONE TANK <br /> �7^ ❑2.ONE IN A COMPARTMENTED UNIT. <br /> L Comleteone eforewhwmetlmentintbemdl. 419 <br /> DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 4J6 NUMBER OF COMPARTMENTS IN THE UNIT <br /> 4/1/1995 15,000 1 <br /> III.TANK USE AND CONTENTS 1c.AVIATION FUELING 439 <br /> TANK USE N la.MOTOR VEHICLE FUELING LJlb.MARINA FUELING <br /> [1 3.CHEMICAL PRODUCT STORAGE [14.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] d39a <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): <br /> CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED N 16.PREMIUM UNLEADED <br /> 440 <br /> [13.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS 440a <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Sped <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 440y <br /> ❑ 11.OTHER NON-PETROLEUMS city: <br /> IV. TANK CONSTRUCTION 443 <br /> TYPE OF TANK ❑ 1.SINGLE WALL N 2.DOUBLE WALL ❑ 95.UNKNOWN <br /> PRIMARY CONTAINMENT ® 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444a <br /> ❑ 7.STEEL+INTERNAL LIFTING ❑ 95.UNKNOWN ❑ 99.OTHER (S ,fy: 445 <br /> SECONDARY CONTAINMENT ❑ 1.STEEL N 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED M5. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 452. <br /> OVERFILL PREVENTION N L AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ ­.FILL TUBE SHUT-OFF VALVE <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQ NT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION abe <br /> PIPING CONSTRUCTION ❑1.SINGLE-WALLED ®2.DOUBL&WALLED ❑99.OTHER 458 <br /> SYSTEM TYPE ® 1.PRESSURE j , 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2616(a)(3)] 4" <br /> PRIMARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464a <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4646 <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ ...RIGID PLASTIC 4Mc <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464d <br /> PIPINGfIURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 90.NONE <br /> VI.VENT,VAPOR RE-0--`(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION 464. <br /> VENT PRIMARY CONTAR,11-Nt ❑ 1.STEEL N 4.FIBERGLASS ❑ l0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4Me1 <br /> 464f <br /> VENT'SECONDARY CONfAINMENf ❑ 1.STEEL N 4.FIBERGLASS [310.RIGID PLASTIC ❑ 90.NONE ❑ 99.GT}IBR(Specify) 4Mn <br /> VR PRIMARY CON'JA1NMENT ❑ 1.STEEL ®'4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464g <br /> 464 1 <br /> x646 <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99,OTHER(Specify) 4MAl <br /> 464i, <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464j <br /> RISER PRIMARY CONCAINMENf ❑ 1.STEEL N 4.FIBERGLASS Li 10,RIGID PLASTIC L] 90.NONE ❑ 99.OTHER(Specify) 4641 <br /> 4Mk <br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4MkI <br /> FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET N 3.STRIKER PLATEBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP <br /> 451a-c <br /> VII.UNDER DISPENSER CONTAINMENT(UDC) 469e <br /> CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469b-c <br /> CONSTRUCTION MATERIAL ❑ I.STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify <br /> VIII. CORROSION PROTECTION 448 <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, <br /> and in full Com lienee with legal re uirements. 470. <br /> APPLICANT SIGNATURE \ _ _ 9 n DATE <br /> U N LSC <br /> 4n. <br /> 471. APPLICANT TITLE Operator/Owner <br /> APPLICANT NAME(print) Joginder Lal L s <br /> Rev.(1220071 <br /> UPCF UST-B-12 <br />