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UNIFIED PROGRAM CONSOLIDATED FORM Q p +2 UNDERGROUND STORAGE TANK (�V(I ,b9\\ OPERATING PERMIT APPLICATION-TANK INFORMATION(one form% TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this tion and Sections I,q 114 IV,and IX below) °R' ❑ I.NEW PERMIT [13.RENEWAL PERMIT 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE [17.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL 43(Ib DATE UST PERMANENTLY CLOSED: 0301 1 DATE EXISTING UST DISCOVERED: I. FACILITY INFORMATION FACH,TfY ID#(Agency Use Only) A _ 0 - � I B SINES NAME(Same as FACILITY Nwn)JE or DBA-Doing Business As) lJ 3 Bus DIu�t D M 1 45 V✓° 105 CITY II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 453 TANKCONFIGURATION: THISTANK IS 434 XL 1.ASTAND-ALONE TANK El 2.ONE N A COMPARTMENTED UNIT. Camlde oro vasa fr eech ml in@e wtil. DATE UST M S'[ ED a35 TANK CAPACITY IN GALLONS 456 NUMBER OF COMPARTMENTS IN THE UNIT 431 C� ( O OZ) III.TANK USE AND CONTENTS TANK USE I..MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ 1c.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE nhdW Us4d O10 ❑ S.EMERGENCY GENERATOR FUEL(RSC 125281.5(c)I ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 43% CONTENTS PETROLEUM: la.REGULAR UNLEADED ❑ 1..MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK 01.SINGLE WALL JS 2.DOUBLE WALL El 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL JR 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444' SECONDARY CONTAINMENT ❑ 1.STEEL LU.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE 95.UNKNOWN ❑99.Ofi{ER(S i ): 445. OVERFILL PREVENTION I. AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. 4.TANK MEETS REQUIREMENTS F f EMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑LSNGLE-WALLED .DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE LPRESSURE El .GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR 42636(.X3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL JNL4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 9J.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Spccify): 464. SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ .OTHER(Specify): 464c PIPING,TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL 2.99DOUBLE WALL 090.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER I FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464c 461e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464f 46sn VR PRIMARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) all&15 VR SECONDARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 46th 464hl VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE W 2.DOUBLE WALL 90.NONE 4641, RISER PRIMARY CONTAINMENT ALL 1.STEEL 4.FIBERGLASS Lj 10.RIGID PLASTIC ❑ 90.NONE LJ 99.OTHER(Specify) 464, 461'1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 4644 464kl FILL COMPONENTS INSTALLED L SPILL BUCKET 05Z3.STRIKER PLATE/BOTTOM PROTECTOR IKA.CONTAINMENT SUMP 451.c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ I.SINGLE WALL 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469. CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469 VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448 DC. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein Is true, and in full compliance with legal requirements. APPLICANT SIGNATURE DATE p r0 APPLICANT NAME(print) 471. 4r.TITLE . .")'411' �- UPCF UST-B-1/2 Rev.