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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],if,III,IV,and IX below) 430 ❑ L NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE. ❑ 7.UST PERMANENT CLOSURE ON SITE X 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION 5 3 I I S FACILITY ID#(Agency Use Only). _ - �Acx)315(4 ) BUSINESS NAME(Same as FACILITY NAMEorDBA-Doing Business As) 3 t S'7<<7Fc/liY7r 5s I", J -s•..I", �x /!!✓i f Ar/r��M/•Fcri�f BUSINESS SITE ADDRESS 103 CITY 1 II.TANK DESCRIPTION TANK ID# 43z TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 I& A STAND-ALONE TANK 2.ONE M A COMPARTMENTED UNIT. 14 n Ai Lv of Complete one page for each com anmeni in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAP CTANK Y IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 14 w I. USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lo.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ,ZQ,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 ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS - ❑ 8.PETROLEUM BLEND FUEL IC 9.OTHER PETROLEUM (specify):0Aln/ of e- 440a NON-PETROLEUM:,7.USED OIL ❑ 10.ETHANOL IV E] 11.OTHER NON-PETROLEU (Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER �a 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER CAa SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑IN ETED , G 445 El 90.NONE El 95.UNKNOWN El99.OTHER(Specify): P [,�. 445a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALV17 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION � PIPING CONSTRUCTION ❑1.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑4.SAFE SUCTION[23 CCR§2636(a)(3)) 458 PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c 4 PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION . VENT PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464. 464el VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464E 464A VR PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4646 464g] VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464i. RISER PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 464'1 RISER SECONDARY CONTAINMENT ❑ L STEEL ❑ 4,FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED ❑ I.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b-e 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 com e a APPLICANT SIGNAT DATE 470.j�/�S� orint 471' APPLICANT TITLE G 472' APPLICANT NAME f UPCF UST-B-1/2 Rev.(12/2007)