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DI �9�_1 sol UNIFIED PROGRAM CONSOLIDATED FORM f� /( 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: 4304 DATE EXISTING UST DISCOVERED: a3ob I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as FACILITY NAME or DB)Doing Business As 3 1/S BUSINESS SITE ADI2E S 1 CITY toa L L l �.(.� '� +✓lam 7rCC C H.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 [:11.A STAND-ALONE TANK 3 RI.-ONE IN A COMPARTMENTED UNIT it. Com tete one page for each com artment m the un . DATE UST436 NUMBER OF COMPARTMENTS IN THE UNIT 437 Q. III.TANK USE AND CONTENTS TANK USE a.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Ic.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: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED B--lV7PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 4aoa NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 440b ❑ 11.OTHER NON-PETROLEUM(Specify): W. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ;2 DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT 21.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99,OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL 9-T. `IBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER(Specify): 445a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS LI 2.BALL FLOAT .FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SI GLE-WALLED DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE PRESSURE ❑ 2. RAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL ET 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4644 SECONDARY CONTAINMENT ❑ 1.STEEL 9rFIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95 UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE Er I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT STEEL ❑ 4.FIB SS ❑ 10464el A .RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC .NONE ❑ 99.OTHER(Specify) 464f 4640 VR PRIMARY CONTAINMENT ❑ L STEEL Er4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464 1 VR SECONDARY CONTAINMENT E] 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PA LSTIC .NONE [199.OTHER(Specify) 464h 464h] VENT PIPING TRANSrriON SUMP TYPE ❑ !!STEEL WALL ❑ 2.DOUBLE WALL NONE 4641. RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE LJ 99.OTHER(Specify) 4641 464j 1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC NONE ❑ 99.OTHER(Specify) 4664k14kI BUCKET TRIKER PLATEBOTTOM PROTECTOR [14.CONTAINMENT SUMP 4514-c FILL COMPONENTS INSTALLED ff�.SPILL VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL .STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC El99.OTHER(Specify) 4696 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 compliance with legal requirements. 470. APPLICANT SIGNATURE DATE J Z Z r) ht I ' E 472. APPLICANT NAME(print) 471. APPLICANT TIT��j� �2 iµ1 UPCF UST-13-1/2 Rev.(12/2007)