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k A5 RECEIV E La +01 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK N ITN OPERATING PERMIT APPLICATION-TANK INFORMATIO TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,11 1! 7,76ff 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: 430, DATE EXISTING UST DISCOVERED: 430h I. FACILITY INFORMATION a6a D /-7:?-- FACILITY (!--FACILITY ID#(Agency Use Only). ` uif:C.3 I BUSINESS NAME(Sameas FACILITY NAME or DBA-Doing Business AAs) C 3 CC</i�/�S �STaT< D BUSINESS SiTE ADDRESS 103 CITY / / 7/1 ri II.TANK DESCRIPTION TANK ID 4 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 1 A STAND-ALONE TANK Lj 2.ONE IN A COMPARTMENTED UNIT. &Ahwiw WA1(r7,0W^ Complete one pagefcreachcom admentintheunit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS iN THE UNIT 437 III.TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ,g.4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5,EMERGENCY GENERATOR FUEL[HSC§25281.5(c)l ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ la,REGULAR UNLEADED ❑ lc.MiDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL 14 9.OTHER PETROLEUM (Specify):4 /j{/A/ Of Z- 440a NON-PETROLEUM:a 7,USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7,STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER(Specify): 445a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.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 ❑2.DOUBLE-WALLED E],99.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVIT ❑ 3..CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION t23 CCR§2636(a)(3)1 458 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FiBER LASS ❑ 8.FLEXIBLE ❑ 10.RIGiD PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RiGiD PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c e PIPING/TU RB INECONTAINMENT SUMP TYPE ❑ 1.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 ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGiD PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464E 464f1 VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10,RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464g 464g 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90,NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PiPiNG TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4641. RiSER PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT ❑ I.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 ❑ 1.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 s em is com atible with the hazardous substance stored and that the information provided herein is true,accurate, and in full co nce a re ' ment 470. APPLiCANTSIGNATU DATE / O _ APPLICANT NAME r�r; - 471. APPLICANT TITLE an. 'ED UST Operating Permit Application-Tank Information Instructions (Formerly SWRCB Permit Application Form B and UPCF Form hwfwrc-b) c e z Complete a separate form for each UST for all new permits,permit changes,and any UST system information changes. This form mu� u�n t m 30 days of permit or UST system information changes,unless your local agency requires approval prior to making changes.For tanks that are part of a compartmentalized unit, each compartment is considered a separate tank and requires completion of a separate Tank Information form.For a UST permanent closure OE`.mrov[i1,4Ait{ttnly TYPE OF ACTION and Sections 1,i1,i1I,IV,and iX.(Note: Numbering of these instructions matches the data element numberes_gpx}}gE �SEa�,�E$ 430. TYPE OF ACTION-Check the appropriate box to indicate why this form is being submitted. ��VV�� 430a. DATE UST PERMANENTLY CLOSED-For reporting closure only:enter the date the UST was removed or closed on site. 430b. DATE EXISTING UST DISCOVERED-Enter the date this UST was discovered.Leave blank if installation date is known. i. FACILITY iD NUMBER-This space is for agency use only. 3. BUSINESS NAME-Enter time complete facility name. 103. BUSINESS SITE ADDRESS-Enter the street address of the facility,including building number,if applicable. This address must be the physical location of the facility.Post office box numbers are not acceptable. 104. CITY-Enter the city or unincorporated area in which the facility is located. 432. TANK ID N-Applicant may enter the owner's tank identification number or leave this space blank.The Local Agency will assign the State tank identification number as the unique identifier for the tank. 433. TANK MANUFACTURER-Enter the name of the company that manufactured the tank. 434. TANK CONFIGURATION.Check the appropriate box to indicate if the tank is a stand-alone tank or one in a compartmented unit.A separate UST Operating Permit Application-Tank Information form must be submitted for each compartment. 435. DATE UST SYSTEM INSTALLED-Enter the date the local agency signed-off on installation of the UST system. This is the date of initial tank system installation,and does not ine]6&upgrades or retrofits which may have been performed later.if this is for a new installation,leave blank. 436. TANK CAPACITY iN GALLONS:Enter the tank capacity. For compartmentalized tanks,enter data for the compartment covered by this tank form only. 437. NUMBER OF'COMPARTMENTS IN THE UNIT:if the tank is a compartment,enter the total number of compartments in the unit. 439. TANK USE-Check the type of tank usage. 439a. If you checked"Other"specify the type of tank usage in the space provided. 440. TANK CONTENTS-Check the specific petroleum or non-petroleum substance stored, 440a. if you checked"Other Petroleum"specify-the common name of the substance in the space provided[i.e.,the name used in the facility's Hazardous Materials Business Plan(HMBP)inventory]. 440b. if you checked"Other"under Non-petroleum,specify the common name of substance in the space provided(i.e.,the name used in the HMBP inventory). 443. TYPE OF TANK-Check the box that identifies the type of tank. 444. TANK PRIMARY CONTAINMENT-Check the construction"material of the primary containment(i.e., inner tank wall nearest the hazardous substance stored). If the tank material is not listed,check"Other"and specify the material in the space provided. 444a. If you checked"Other"specify the type of primary containment in the space provided. 445. TANK SECONDARY CONTAINMENT-Check the construction material of the secondary containment that provides containment external to,and separate from,the primary containment described above. If the tank is a single-wall tank,check"None." If the material is not listed,check"Other' and specify the material in the space provided(e.g.,HDPE). 445a. If you checked"Other"specify the type of secondary containment in the space provided. 452 OVERFILL PREVENTION-Check the box(es)to describe the type(s)of overfill protection equipment installed. 458. PIPING SYSTEM TYPE-Check the type of product/waste piping installed in this tank system. "Safe suction" refers to piping systems meeting all requirements of 23 CCR§2636(a)(3)(also known as"European Suction"systems)(i.e.,sloped suction piping systems with no valves or pumps below grade and only one check valve, located below and as close as practical to the suction pump). Title 23,California Code of Regulations is available online at www.calre2s.com. 460. PiPiNG CONSTRUCTION-indicate if the piping is single-walled or double-walled,or"other". 464. PIPING PRIMARY CONTAINMENT-Check the materiAI(s)used to construct the primary(i.e.,inner)underground product/waste piping. 464x. If you checked"Other"specify the type of primary containment in the space provided. 464b. PIPING SECONDARY CONTAINMENT-Check the material(s)used to construct the secondary containment system(s)(i.e.,secondary piping,trench) provided for the product/waste piping.For single-wall piping systems,check"None." 464c. If you checked"Other"specify the type of secondary containment in the space provided. 464d. PIPING/fURBINE CONTAINMENT SUMP TYPE-Indicate the type of piping/turbine containment sump(s).Check"None"if not present. 464e-el VENT PRIMARY CONTAINMENT-Check the material(s)used to construct the primary(i.e.,inner)vent piping. (Note:Address venting of the tank primary containment only,)Specify Other type of containment in the space provided. 464f-fl VENT SECONDARY CONTAINMENT-Check the material(s)used to construct the secondary containment system(s)(e.g.,secondary piping,)provided for the vent piping. For single-wall piping systems, check "None." (Note: Address venting of the tank primary containment only.) Specify Other type of containment in the space provided. 4648-g1 VR PRIMARY CONTAINMENT-Check the material(s)used to construct the primary(i.e.,inner)vapor recovery piping. For tanks without vapor recovery piping(e.g.,Diesel tanks),check"None." Specify Other type of containment in the space provided. 464h-h I VR SECONDARY CONTAINMENT-Check the materials)used to construct the secondary containment system(s)(e.g.,secondary piping)provided for the vapor recovery piping.For single-wall piping systems,check"None." Specify Other type of containment in the space provided. 464i. VENT PIPING TRANSITION SUMP TYPE-Indicate type of transition sump(s).Check"None"if not present. 464j-j I RISER PRIMARY CONTAINMENT-Check the material(s)used to construct the primary(i.e.,inner)piping for all risers(not drop tubes)other than annular space risers(i.e.,risers for filling or gauging of the primary tank). Specify Other type of containment in the space provided. 464k-ki RISER SECONDARY CONTAINMENT-Check the material(s)used to construct secondary containment system(s)(i.e.,secondary piping,sumps)provided for the riser piping.For risers without secondary containment,check"None." Specify Other type of containment in the space provided. 45la-c. FILL COMPONENTS INSTALLED-Check the appropriate boxes to show that spill containment, tank bottom protection,and fill containment sumps(if applicable)are installed. 469a. UDC CONSTRUCTION TYPE-Check the box to describe the type of dispenser containment system(s)(i.e.,dispenser sumps or pans). If the system has no dispensers(e.g.,standby generator tank system),check"No Dispensers." if the system has a dispenser,but no UDC,check"None". 469b. UDC CONSTRUCTION MATERIAL-Check the box to describe the materials used to construct the UDC. 469c. Ifyou checked"Other"specify the construction material in the space provided. 448. STEEL COMPONENT PROTECTION-Ali systems contain some steel components. Check time appropriate box(es)to describe all corrosion protection methods used. "Isolation"means electrical isolation from soil, backfill,and groundwater. Examples include fiberglass cladding,non-metallic secondary containment systems which isolate steel components from the sub-surface environment,and insulating bushings. APPLICANT SIGNATURE-The same person who signs the UST Operating Pen-nit Application-Facility information Form shal I sign in the space provided. This signature certifies that the signer believes that all information submitted is true and accurate,and that the UST system is compatible with the.hazardous substance stored_. - V t-i a J V W RE-C IVFD UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK JAN 0 6 2015 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 SectionOKF TH 430 El1.NEW PERMIT M 3.RENEWAL PERMIT El5.CHANGE R\IlGES El 6.TEMPORARY UST CLOSURE. ❑ 7.UST PERMANENT CLOSURE ON SITE 8.UST 1 OVALPE W DATE UST PERMANENTLY CLOSED: 430. DATE EXISTING UST DISCOVERED: 4306 \ 1 I. FACILITY INFORMATION FACILITY iD#(Agency Use Only) /v h BUSINESS NAME(Same as FACILITY YNAME oorr"DBA-Doing Business As) 3 CcI-Ar-S -STc 4< O I C, A ,A.2-71c /r 9 .SiYq.sfscAJiEw !!I-✓, lei o,c ��fnt•Fc�i� BUSINESS SITE ADDRESS 103 CITY J 0i W IL TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 ($1.A STAND-ALONE TANK ❑2,ONE IN A COMPARTMENTED UNrr.. L(n/rof a;WA A le04WJ" Complete one pagefor each com arlment in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS A36 NUMBER OF COMPARTMENTS iN THE UNIT 437 III.TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCTSTORAGE ;K4,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 ❑ lc.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6,AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL Pj 9.OTHER PETROLEUM (Specify):Ojep OR j9Y.*V O f 4 440a NON-PETROLEUM:),7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ I.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNALLINiNG ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER(Specify): 445a OVERFiL,L PREVENTION ❑ 1.AUDIBLE&ViSUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.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 ❑2.DOUBLE-WALLED [-199,OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(.)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RiGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c 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 ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGiD PLASTIC ❑ 90.NONE ❑ 99,OTHER(Specify) 464f 464f1 VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10,RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464g 464SI VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RiGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE ❑ 1.SiNGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464i. RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATEBOTTOM 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 ❑ 1.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 s stem is corn a with the hazardous substance stored and that the information provided herein is true,accurate, and in ful ranee w recluiTmilents. APPLiCANTSiGNAT - DATE 470. APPLICANT NAME inrint 471' APPLICANT TiTi,F 472. UPCF UST-13-1/2 Rev.(12/2007)