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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK 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,B,III,IV,and DC below) 430 ❑ L 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: 439. DATE EXISTING UST DISCOVERED: 430b 1. FACILITY INFORMATION FACILITY ID#(Agency Use Only) I BUSINESS NAME Same es FACIICT NAME or DBA-Doing Burin s As) 3 �r a cam. l.�' �,•�tL � � BUSINESS SITE ADDRESS l03 S�- Cf,Y m,a N f e Gc� 94 IL TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 TA D/ S ( DS �(JC/�h ❑2.ONE IN A COMPARLOW ATMENTED UNIT. C ae one fm®cM1 wm anma:�dt DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 yvrle> III.TANK USE AND CONTENTS TANK USE RC1 Ia.MOTOR VEHICLE FUELING [I lb.MARINA FUELING [IIc.AVIATION FUELING 439 L.I 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(hMuda Ueed Gip ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 43% CONTENTS PETROLEUM: ❑ ]a.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 3.DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ' I.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT 5.] 1.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 ,,.UNKNOWN ❑99.OTHER(S ): 445e OVERFILL PREVENTION ❑ L 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 ❑1.SINGLE-WALLED IX 2.DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑4.SAFE SUCTION 23(MR§263b(eX3)11 458 PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 'IM. SECONDARY CONTAINMENT ❑ L STEEL Ek 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC *lb 0^90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): +64c PIPINGITURBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4Md VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT L STEEL ❑ 4.FIBERGLASS C1 10.RIGID PLASTIC D 90.NONE ❑ 99.OTHER(Specify) 464e 469 1 VEIN SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 464f VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ UI RIGID PLASTIC (a 90.NONE ❑ 99.OTHER(Specify) 44Mg 464 1 VR SECONDARY CONTAINMENT ❑ LSTEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC (-r] 90.NONE ❑ 99.OTHER(Specify) 461h 464h1 VENT PIPING TRANSITION SUMP TYPE L SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT L STEEL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 4641 46M01 RISER SECONDARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464k 4 Ikl FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATFIBOTTOM PROTECTOR 4.CONTAINMENT SUMP 451.-c VII.UNDER DISPENSER CONTAINMENT(UDC), , I CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE - 4694 CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS CR 10.RIGID PLASTIC ❑ 99.OTHER(5 ify) d. 4696c VIIL CORROSION PROTECTION 4w _ STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448, IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substitute stored and that the information provided herein is trlfeyalcurate, and in fug compliance with legal puirements. APPLIC SIGNATURE DATE / r _ /�-t n 470. S-SS >, `-1 / APPL ANT NAME(print) 491 I APPLICANTTITLE t G W fj UPCF UST-B-1/2 Rev.(12/2007)