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0 & (6)( 09- '�20hl UNIFIED PROGRAM CONSOLIDATED FORM �) UNDERGROUND STORAGE TANK 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,II,III,IV,and IX below) 430 ❑ 1.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: 430a DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ _ 12161-31-3 1 BUSINESS NAME(Same as FACILITY NAME or DBA-D ing usines s) �rJ 3 0.A, L) �'` BUSINESS SITE ADDRESS GY i 103 1 TY s" 104 2 �✓ I � II.TANK DESCRIPTION IV TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 ` 1.A STAND-ALONE TANK (� / J �r 2 2 Q� ❑2.ONE IN A COMPARTMENTED UNIT. 1 `J V -._l u Complete one page for each compartment in the unit DATE UST SYSTEM INSTALLED 435 TANK CAP CITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 0_0 I1I.TANK USE AND CONTENTS TANK USE a.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: OT.REGULAR UNLEADED ❑ ]c.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL M-3-FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL [4o3 MERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 4458 OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT 9--5'. ILL 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 DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL �4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN [1 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT .STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464f 4641`1 VR PRIMARY CONTAINMENT ❑ L STEEL FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464g) VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL NONE 4641. RISER PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC .NONE ❑ 99.OTHER(Specify) 4641 464'1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0.NONE ❑ 99.OTHER(Specify) 464k 4641 FILL COMPONENTS INSTALLED B11PILL BUCKET STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE R1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448 IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full co liance with legal requirements. APPLICANT SIGNATURE DATE 470. 2 APPLICANT NAME(print) F z 471" APPLICANT TITLE j 472. c` ►� b f T UPCF UST-B-1/2 Rev.(12/2007)