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RECEIVED UNIFIED PROGRAIII CONSOLIDATED FORM :A,UG O 4 2013 UNDERGROUND STORAGE TANK OPERATINGPERMIT APPLICATION-TANK INFORMATION(One foecuST) 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 ❑ 1.NEW PERMIT [R3,RENEWAL.PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY US`T CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ S.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4300 1 DATE EXISTING UST DISCOVERED: 43ob I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) ILi 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 rA 5 T N 6-4,1 ' I d BUSINESS SITE ADDRESS107 CITY 104 9 o w� c �� tr`la��e� c.a q S33 6 II.TANK DESCRIP'T'ION:, TANK ID 432 TANK MANUFACTURER 433 TANKCONFIOURATION; TmSTANKIS 494 Erf A STAND-ALONE TANK 6011C to 1*� ❑2,ONE IN A COMPARTMENTED EO UNIT, Com lex.one Rage for each rom artment in the W61L DATE UST SYSTEM 1NSTA,LED 475 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN TETE UNIT 437 10 - :3 l0 00C] III.TANK USE AND CONTENTS TANK USE rYr..MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ ]c.AVIATION FUELING 439 ❑ 3,CHENUCAI.PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Indudoe Used Oil) ❑ S.EMERGENCY GENERATOR FTJEL[HSC 425291.5(c)1 ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify)! 439a CONTENTS PETROLEUM; a.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib,PRBMIUM UNLFADED 440 ❑ 3,DIESEL ❑ 5.IET FUEL ❑ 6,AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (S eci 440a NON•PETROIEUM;❑ 7,USED OIL 1' 10.ETHANOL ❑ 11.OTHERNON-PETROLEUM S eci 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 403 PRIMARY CONTAINMENT ❑ 1.STEEL EK3.FIBERGLASS ❑ 6.INTERNAL BLADDER 404 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify); 444. SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MF1,IBRANE LINER ❑ 7,JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 4452 OVERFILL PREVENTION I.AUDIBLE&VISUAL ALARMS El 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452, ❑ 4.TANK NiEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT `V:.PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑LSINGLE-WALLED ,DOUl3LF.WALLED [199-OTHER 460 SYSTEM TYPE 2-7..PUSSURk ❑ 2.GRAVITY 3.CONVENTIONAL SUCTION F-14,SAFE SUCTION[23 CCR§2635(4)(3)] 456 PRIMARY CONTAINMENT ❑ 1.STEEL E4'r FIBERGLASS ❑ 8.FLEX7BLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(S eci ): 4641 SECONDARY CONTAINMENT ❑ L STEEL ErC FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURaINE LONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL. ❑ 2.DOUBLE WALL ❑ W.NONE 464d VI.VENT;VAPOR RECOVERY(VR)AND RISER/FILL P1PE,PJPING.CONSTRUCTION VENT PRIMARY CONTAINMENT .STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.0THER(Specify) .464e 464c VENT SECONDARY CONTAINMENT STEEL 4,FIBERGLASS ❑ ID.RIGID PLASTIC E] 90.NONE 99.OTHER(Specif2) 464f 464f1 VR PRIMARY CONTAINMENT ❑ I-STEEL M-4.FIBERGLASS Li 10.RIGID PLASTIC ❑ 90,NONE ❑ 99,OTHER(Specify) 4648 464•t VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 1o.RI01D PLASTIC 90.NONE 0 99.OTHER(Specify) 464h 4601 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL El 2.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT 1,STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 464i1 RISER SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 4641 FILL,COMPONENTS INSTALLED 1.SPILL BUCKET Kr3,STRIKER PLATEIBOTTOM PROTECTOR El 4.CONTAINMENT SUMP 4514-4 VII.UNDER,DISPENSER CONTA.INNIENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEF ff4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99,OTHER(Specify)_ 469b-c VTIl. CORO.OSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES) ❑ 4,IMPRESSED CURRENT ❑ 6.ISOLATION 448. IN. APPLICANT SIGNATURE CERTIFICATION- I certify tha this UST system is compatible with the hazardous substAnce,stored aid that the information Drovlded herein is true,accurate, and in fu11 'ance with legal requirements. APPLICANT SIGNATURE DATE 470. APPLICANT NAME(prin 471. APPLICANT TITLE 472 �')1,14Pl1vtt Otrr40 ot.m"cY UPCF UST-B-112 Rev.(12/2007)