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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per LIST) <br /> TYPE OF ACTION (Check ane item oniv For a UST closure or remowl.complete only this section and Sections Ill.111./F,and IX below) 450. <br /> ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ® 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 410. I DATE EXISTING UST DISCOVERED: 0% <br /> I. FACILITY INFORMATION <br /> FACILITY ID g(Agency Use Only) I. <br /> ISUSINESS NAME(Same as FacilftyArame or DBA-Doing Business ds) 3 <br /> USA/Tesoro <br /> BUSINESS SITE ADDRESS 193. CRY Iw <br /> 13975 E. Hiway 88 1o,L-ford <br /> II. TANK DESCRIPTION <br /> TANK ID# 432 TANK MANUFACTURER 413 TANK CONFIGURATION:THIS TANK IS 454 <br /> 2 STIP ® L A STAND-ALONE TANK Ca�pinaaw py4fw«b <br /> ].ONE INA COMPARTMENTED UNIT wmp4emmi i.Ov w4. <br /> DATE UST SYSTEM INSTALLED ... TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS M THE UNIT 437 <br /> 1990 1 10.000 <br /> I <br /> III. TANK USE AND CONTENTS <br /> TANK USE IN le MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 <br /> C3 I.CHEMICAL PRODUCT STORAGE ❑ 4 HAZARDOUS WASTE(Ialu4m L.cwi Od) p 5.EMERGENCY GENERATOR FUEL[HSC§25231.5(c)I <br /> p 6.OTHER GENERATOR FUEL _ _Q 95. UNKNOWN _ p 99.OTHER S <br /> CONTENTS PETROLEUM: ❑ Ia REGULAR UNLEADED ® Ic.htR)GRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440- <br /> § 3.DIESEL ❑ 5.JET FUEL p 6.AVIATION GAS <br /> 0 8.PETROLEUM BLEND FUEL p 9.OTHER PETROLEUM(Specify)'_ 440. <br /> -_ ._ __. - 1 - - -._ <br /> NON-PETROLEUM ❑ ).USED OIL p 10 ETHANOL <br /> p 1 L OTHER NON-PETROLEUMS ci I: a40b <br /> IV. TANK CONSTRUCTION <br /> ffSECONMRY <br /> p 1_SINGLE WALL N 2.DOUBLE WALL ❑ 95.UNKNOWN <br /> INMENT ® I.STEEL <br /> ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 4ai <br /> _. ,_ 7.STEEL+INTERNAL LINING ❑ 95 UNKNOWN ❑ 99.OTH_ER_(_Spccify):NTAINMENT 1.STEEL p 3.FIBERGLASS ❑ n EXTERIOR MENIBRANELINER ® 7 IACKEfED 445 <br /> p 90 NONE p 95.UNKNOWN ❑99.OTHER(Specify) 445. <br /> NTION p 1.AUDIBLE&VISUAL ALARMS ❑ 2 BALL FLOAT ® 3.FILL TUBE SHUT-OFF VALVE 452 <br /> 4.TANK MEETS RE UIREMEN IS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION _ _ ❑ I.SINGLE.WALL ® ?.DOUBLE WALL ❑ 99 OTHER 460 <br /> SYSTEM TYPE ® I.PRESSURE p GRAVITY p 3 CONVENTI.O_NAL_SUCTIONp 4 SAFE SUCTION_IZ3 CCR 42mWax511, _ 411 <br /> -_- <br /> PRIMARYCONTAINMENT p 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE <br /> p 90.NONE ❑ 10.RIGID PLASTIC 464 <br /> -________ 95 UNKNOWN _p 99.OTHER(Specify l: 464. <br /> SECONDARY CONTAINMENT p 1.STEEL ® 4 FIBERGLASS p 8.FLEXIBLE p 10.RIGIDPLASTIC 4646. <br /> _-__ -_____ 0 90.NONE p 95 UNKNOWN p 99.OTHER ISpecdyt 464c. <br /> PIPINGITURBINE CONTAINMENT$UMP TYPE ® I.SINGLE WALL ❑ i DOUBLE WALL ❑ 90.NONE 4s4a. <br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ® L STEEL p 4.FIBERGLASS p 10.RIGID PLASTIC ❑ 9V.NONE p 99.OTHER(Specify): <br /> VENT SECONDARY CONTAINMENT p I STEEL ❑ 4.FIBERGLASS p 10.RIGID PLASTIC ® 90.NONE p ".OTHER IS I61B <br /> VR PRIMARY CONTAINMENT ❑ 1 STEEL ® 4 FIBERGLASS p 10.RIGID PLASTIC ❑ W.NONE p 99.OTHER(Specify): 464a <br /> VR SECONDARY CONTAINMENT p 1 STEEL ❑ 4.FIBERGLASS p 10.RIGID PLASTIC ® W.NONE p 99.OTHER(Specify): 4 <br /> VENT PIPING TRANSITION SUMP TYPE p 1.SINGLE WALL p 2.DOUBLE WALL ® 90.NONE 464' <br /> RISER PRIMARY CONTAINMENT ® 1 STEEL ❑ 4.FIBERGLASS p 10.RIGID PLASTIC p 90.NONE p 99.OTHER(Specify): '1643 <br /> RL$ER SECONDARY CONTAINMENT ❑ I STEEL ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ® 90 NONE p W.OTHER(Specify) 4th k. <br /> FILL COMPONENT$INSTALLED ® I SPILL BUCKET ® 3.STRIKER PLATHBOTTOM PROTECTOR ❑ 4 CONTAINMENT SUMP 451«. <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> _ CONSTRUCTION TYPE ® I SINGLE WALL ❑ 2 DOUBLE WALL_ p 3.NO DISPENSERS p 90.NONE 469. <br /> CONSTRUCTION MATERIAL ® I.STEEL p 4 FIBERGLASS p 10.RIGID PLASTIC ❑ W OTHER(Specify) ; <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ® 2.SACRIFICIAL ANOD S ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 446 <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, <br /> accurate and in full compliance with Ing]Muirement, <br /> APPLICANT SIGNATURE. ,i DATE 6/8/2009 <br /> APPLICANT NAME(print) Sandy ENvards u.. 411 APPLICANT TITLE Environmental Compliance 4TL <br /> UPCF UST-B Rev.(12/2007)-12 www.unidoc&osg <br />