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UNIFIED PROGRAM CONSOLIDATED FO v X11` UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One fo m per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this��n and Sections I,[I,III,IV,and IX below) 430 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT jTy�S.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ONSITEE S.UST REMOVAL 430b DATE UST PERMANENTLY CLOSED: DATEXISTING UST DISCOVERED: I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) Al - C - 1 BUSINESS NAM (SS�F4CIG�j AME DBA-Doing Business As) 3 L wRS�� L4 BUS S$ S t 10' .1A CITY 4.) �i"I E14 II.TANK DESCRIPTION TANK ID# 432 TANK M4,NUFACTURERr�^�1 413 TANK CONFIGURATION: THIS TANK IS 414 �� / ❑1.ASTANALONE ACOMPATANK U r54r.�,T-^' ONE INA COMPARTMENTED UNR. o� COT IdeoM fr each con in nrcurvt DATE U$T SILTIM61TALLED 435 TANK CTTY M GALLONS 436 NUMBER OF COMP�MENTS IN THE UNIT 437 GU III.TANK USE AND CONTENTS TANK USEIa.MOTOR VEHICLE FUELING [I It.MARINA FUELING ❑ IC.AVIATIONFUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Ihdu Ua Ol) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§2528L5(c)] CI 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 43% CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ le.MIDGRADE UNLEADED 25LIb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S i ): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 11.OTHER NON-PETROLEUMS i : 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT Ll1.STEEL RAL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL INTERytt,LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S ): 444a SECONDARY CONTAINMENT ❑ I.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER($ i ): 445a OVERFILL PREVENTION i.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 ❑L SINGLE-WALLED 2.DOUBLE-WALLED [0199.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR g2636(a)(3)1 458 PRIMARY CONTAINMENT 1.STEEL )0-4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4Ma SECONDARY CONTAINMENT ❑ 1.STEEL KI 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGfrURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 4wd VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I.STEEL 194.FIBERGLASS ❑ 10.RIGID PLASTIC C3 90.NONE CI 99.OTHER(SPeclfy) 46ae 464e1 VENT SECONDARY CONTAINMENT ❑ I.STEEL X1 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) a6af 464Fl VR PRIMARY CONTAINMENT ❑ 1.STEEL 1Z 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) aha g VR SECONDARY CONTAINMENT 0 L STEEL 1&4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 46461 VENT PIPING TRANSITION SUMP TYPE El 1.SINGLE WALL IS 2.DOUBLE WALL ❑ 90.NONE 4641. RISER PRIMARY CONTAINMENT El 1.STEEL EL 4.FIBERGLASS 10.RIGID PLASTIC 0 ,0 90ONE G 99.OTHER(Specify) 4Mj 464'1 RISER SECONDARY CONTAINMENT 1.STEEL R 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED LSPILLBUCKET -3.STRIKER PLATE/BOTTOM PROTECTOR CCONTAINMENT SUMP 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469+ CONSTRUCTION MATERIAL ❑ L STEEL IQ4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 44a IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the Information provided herein Is Ow,accurah, and in full compliance with legal requirements. SC"'""" j APPLICANT SIGNATURE DATE 470. APPLICANT NAME(print) APPLICANTTITLE 472' UPCF UST-B-112 Rev.(1712007)