BILLING 2010 - 2015 - Laserfiche WebLink

Home Browse Search

UNIFIED PROGRAM CONSOLIDATED FORM O UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) l TY3FtF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,11,III,IV,and 1X 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: 431a I DATE EXISTING UST DISCOVERED: 430b 1. FACILITY INFORMATION - FACILITY ID#(Agency Use Only) _ _ 2 I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) c� 3 IXAC BU E$S SITE ADDELESS /�� ?j >l'Ar 103 CITY YT-37 7 104 II.TANK DESCRIPTIIOO'N TANK ID# 432 TANK MANUFACTURER 433 TAN FIGURATION: THIS TANK IS 434 ,/f/J I O'.(11A � ` 1.A STAND-ALONE TANK ///\/,qv/ /✓'!/V/ ❑2.ONE IN A COMPARTMENTED UNIT. Complete one page for each compartment in the unit. DATE U 3S�Y TEM INT L E 435 TANK CAPACITY IN G�QNS 436 NUMBER OF CO NTS IN THE UNIT 437 v u III.TA9K USE AND CONTENTS TANK USE a.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL IHSC§25281.5(c)] ❑ 6.OTHER GENERATO EL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: 1 a.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 Ea 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): 440b . TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL MF2.DOUBLEWALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL Er.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNALL G ❑ 95.UNKNOWN El99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER(Specify) 445. LA OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ARMS ❑ 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 ❑ I.SINGLE-WALLED DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95. NKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL WT FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT TEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC .NONE ❑ 99.OTHER(Specify) 464f 464f1 VR PRIMARY CONTAINMENT EL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC [?-J-9@0.-NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALLONE 4641. RISER PRIMARY CONTAINMENT L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 464j 4641 l RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464k 4641 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451 a-c II.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1. INGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIALI.STEEL ❑ 4.FIBERGLASS [110.RIGID PLASTIC El 99.OTHER(Specify) 46%, VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ISOLATION 448. hN IX. APPLICANT SIGNATURE CERTIFICATION: I certify that is U sys m is compatib with the hazardous substance stored and that the information provided herein is true,accurate, and in full li ce w' le al re iWrits. APPLICANT SIGNATURE DATE APPLICANT NAME lG� 471. APPLICANT TIT < /� a7z. 12-21 UPCF UST-B-1/2 Rev.(12/2007)