COMPLIANCE INFO_2016 - 2018 - Laserfiche WebLink

Home Browse Search

UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK APR o 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 I,11,III,IV,and IX below) 430 ❑ L NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 431 DATE EXISTING UST DISCOVERED: 4301, I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) C�INN" 1 ` - BUSINESS SITE ADDRESS163 CITY urs 1�7,g�1 c.V1r�r�cr L-).-, t� �n CQ II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONF[UU RATION; THIS TANK IS 454 1.A STAND-ALONE TANK 2,ONE IN A COMPARTMENTED UNIT. Cnm lele one page far each cam mens in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 O III.TANK USE AND CONTENTS TANK USE R I..MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE. ❑ 4.HAZARDOUS WASTE(Includes Used Oil ❑ 5.EMERGENCY GENERATOR FUEL IHSC§25281.5(e)l ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: la.REGULAR UNLEADED ❑ le.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 4ao 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S ci r 440. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT I.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ L STEEL [13.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN 99.OTHER S ecif): 445. OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS J�V 2.BALL FLOAT ❑ 3.JILI,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 JR2.DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR§2636(-}{3)) 458 PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS 8.FLEXIBLE ❑ � ❑ 10.RIGID PLASTIC 464 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Spmify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4,FIBERGLASS 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4641, ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ L STEEL )9 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464c 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL Ej 4.FIBERGLASS ❑ 10.RIGID PLASTTC `g 90.NONE ❑ 99.OTHER(Specify) 464r 46411 VR PRIMARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464g] VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ l0.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 94.NONE 4641. RISER PRIMARY CONTAINMENT1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 40.NONE ❑ 99.OTHER(Specify) 464j RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99,OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451.-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ L STEEL ❑ 4.FIBERGLASS RE RIGID PLASTIC ❑ 99.OTHER(Specify) 4696-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and In full cam Ifance with le a_ Imlulrements, APPLICANT SIGNATURE - DATE 470. 4-3-16 APPLICANT NAME(print) 471. APPLICANT TITLE 472. V\(%r. {' (% UPCF UST-B-112 Rev.(12/2007)