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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,11,111,IV,and IX below) 430 <br /> 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ S.CHANGE OF INFORMATION <br /> 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE Q &UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430. DATE EXISTING UST DISCOVERED: 430b <br /> I. FACILITY INFORMATION 71 <br /> FACILITY ID#(Agency Use Only) 1 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 <br /> sant oA 0 uIN <br /> BUSINESS SITE ADDRESS 10.3 CITY 104 <br /> s roc <br /> II.TANK DESCRIPTION <br /> TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 <br /> C o ni 7-A)N/W J=- n/7" RI.A STAND-ALONE TANK <br /> S o L V ?'!o h15 =2.ONE <br /> m IN page for e.COMPARTMENTED <br /> ch co�INea�UNIT. <br /> DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 <br /> O L G.la C <br /> III.TANk USE AND CONTENTS <br /> TANK USE Is.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 <br /> 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL CHIC§25281.5(c)) <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439. <br /> CONTENTS PETROLEUM: i4 In.REGULARUNLEADED ❑ Ic.MIDGRADEUNLEADED ❑ lb.PREMIUM UNLEADED 440 <br /> ja 3.DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440+ <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ l I.OTHER NON-PETROLEUMS 440b <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL $ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL Ig 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444. <br /> SECONDARY CONTAINMENT C1 1.STEEL JZ3.FIBERGLASS 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S i ): 445a <br /> ✓ERFILL PREVENTION I.AUDIBLE&VISUAL ALARMS 0 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-WAILED [12.DOUBLE-WALLED ❑99.OTHER 460 <br /> SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR§2636(.)(3)) 458 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99. S ify): 464& <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c <br /> PIPINGfrURBINE 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 C3 90.NONE ❑ 99.OTHER(Specify) 464c <br /> 464el <br /> VENT SECONDARY CONTAINMENT Lj 1.STEEL $} 4.FIBERGLASS ❑ 30.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f <br /> 464£1 <br /> VR PRIMARY CONTAINMENT D 1.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE L3 99.OTHER(Specify) 464; <br /> 464 I <br /> VR SECONDARY CONTAINMENT D 1,STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 464h <br /> 464hl <br /> VENT PIPING TRANSITION SUMP TYPE J9 2.DOUBLE WALL 90.NONE 464 <br /> RISER PRIMARY CONTAINMENT (23 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464i <br /> 464'1 <br /> RISERSNDARYC 0 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k <br /> 4601 <br /> FHL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR JS 4.CONTAINMENT SUMP 45Irc <br /> VII.UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469■ <br /> CONSTRUCTION MATEAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b{ <br /> RI <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL.ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448• <br /> UL 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 hili compliance with legal r uire <br /> .'PLICANT SIGNA DATE no. <br /> APPLICANT NAME(pont) �� ������ 471 472 <br /> APPLICANT TITLE ^c�'N-r->7 <br /> rrw c rrc rix_t n Rev_!12/20071 <br />