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• • RECEIVED UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK FES 14 2014 OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per US TYPE OF ACTION (Check one item only. Form UST permanent closure or removal,complete only this section and Sections L I Ifto. '�.1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFOIM DEPARTMENT ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430. 1 DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use 0,dy) BUSINESS NAME(Same as4CILITY o D � in BI SI'm 'Aqj� C/ 3 BUSINESS SITE ADDRESS Gt) V`/(�t03 CITY . 4533 la4 F_• F4iTE AVC . M IV-::-C-ki II.TANK DESCRIPTION TANK ID# U S k),5 O 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 [11.A STAND-ALONE TANK g[2.0NE INA COMPARTMENTED UNIT. Com tete we foreaeh tour manta in Ne wit DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMEITS IN THE UNIT 437 III.TANK USE AND CONTENTS TANK USE M In.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(h lodes Used 04) ❑ S.EMERGENCY GENERATOR FUEL[HSC W281.50)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 039a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED la MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL 5!lET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OH, ❑ 10.ETHANOL ❑ 11.OTHER NON.PETROLEUM(Specify): 9406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 162.DOUBLEWALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHERS ecif : 444. SECONDARY CONTAINMENT 14 L STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99 OTHER S ecify): 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 ❑L SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 25 CCR 2636(.x3) 4ss PRIMARY CONTAINMENT ❑ L STEEL1QJ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL IQ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGTrURBINE CONTAINMENT SUMP TYPE W I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS El 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 4640 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 4Nf 46411 VR PRIMARY CONTAINMENT ❑ 1.STEEL �, 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 4MI, 4M9I VR SECONDARY CONTAINMENT ❑ LSTEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL JK 90.NONE 4ML RISER PRIMARY CONTAINMENT 10 L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464j 464 1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE [199.OTHER(Specify) 464k 44k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET K3.STRIKER PLATE/BOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 451.-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NODISPENSERS ❑ 90.NONE 469. CONSTRUCTION MATERIAL ❑ 1.STEEL Mi.4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT K 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 fulfcompliance with legal requirements. APP I DATE 470. APPLICAN Lint) •I_ 401' APPLICANTTITLE 472. c _. Pr UPCF UST-B-1/2 Rev.(12/2007)