Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) <br /> TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,III,IV,and D(below)L 430 <br /> I.NEW PERMrr [13.RENEWAL PERMrr ❑ 5.CHANGE OF INFORMATION <br /> 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 43011 DATE EXISTING UST DISCOVERED: 430b <br /> I. FACELITY INFORMATION <br /> FACIII''TY ID#(Agency Use Only) IT I <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 <br /> SA. rel D V L N <br /> BUSINESS SITE ADDRESS l03 CITY 104 <br /> STD <br /> II.TANK DESCRIPTION <br /> TANK 11)# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 <br /> '1C O r4 'TA 1 NAY)H n17- al.A STAND-ALONE TANK <br /> P*Z*11S a L V Z`1 D hI S ❑2.ONE IN A COMPARTMENTED UNIT. <br /> Com etc ono page for ewb mmpartmewm the unit <br /> DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNN 437 <br /> 440y . AbNz L Gf7 C <br /> III.TANk USE AND CONTENTS <br /> TANK USE In.MOTOR VEHICLE FUELING [I 1b.MARINA FUELING ❑ lc.AVIATION FUELING 439 <br /> 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Inrludn Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC 4252813(c)) <br /> ❑ <br /> 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4391 <br /> CONTENTS PETROLEUM: In.REGULARUNLEADED ❑ Ic.MIDGRADEUNLEADED ❑ 1b.PREMIUM UNLEADED 440 <br /> 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ <br /> 11,OTHER NON-PETROLEUMS 440b <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL J9 2.DOUBLE WALL ❑ 95.UNKNOWN 443 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL $ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 <br /> ❑ 7.SI'EEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (specify): 444a <br /> SECONDARY CONTAINMENT 1.STEEL jai.FIBERGLASS 0 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 44S <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER S i ): 445a <br /> �-� ✓ERFILL PREVENTION 1.AUDIBLE. VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑1.SINGLE-WALLED Q 2.DOUBLE-WALLED ❑99.OTHER 460 <br /> SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR 52636(a)(3)) 458 <br /> PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(S ify): 464a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d <br /> VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464c <br /> 464eI <br /> VENT SECONDARY CONTAINMENT rj 1.STEEL -0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f <br /> 464n <br /> VR PRIMARY CONTAINMENT 1.STEEL fig 4.FIBERGLASS 0 10,RIGID PLASTIC ❑ 90.NONE Ij 99.OTHER(Specify) 4641 <br /> 464 I <br /> VR SECONDARY CONTAINMENT 1.STEEL @ 4.FIBERGLASS C1 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 464b <br /> 4601 <br /> VETT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 4641 <br /> RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464i <br /> 4641 <br /> RISER SECONDARY CONTAINMENT 1.STEEL ❑4.FIBERGLASS to.RJGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464k <br /> 464k1 <br /> FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 4511 <br /> VII.UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 4691 <br /> CONSTRUCTION MATERIAL ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696 c <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448• <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 compliance with! al r uir <br /> ,,PLICANT SIGNA DATE 470. <br /> APPISCANTNAME(print) N P'F-7.�p�0 471. APPLICANTTITLE C a 7- a 472. <br /> rrw^n rx T_R_ n Rev_(12/20071 <br />