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[PIED PROGRAM CONSOLIDATED FORMW UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) 430 TYPE OF ACTION (Check one item only. Tot•ajIS7'closure or removal,complete only this section and Sections],H.111,11',and IX belmt) ❑ 1.NEW PERMIT $`3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON STTE ❑ 8.UST REMOVAL. 43oh DATE UST PERMANENTLY CLOSED: _. 43U2 DATE EXISTING UST DISCOVERED: I. FACILITY INFORMATION 1. 3 FACILITY ID#(Agency Use Onl)) F A - lam. Q d - -7 3 BUSINESS NAME(Same as Facila),Name or DBA-Doing Business As) MAIN STREET Ajg Lo AMPM - V- �S PNt-9,KJSF- Li_c- BUSINESS SITE ADDRESS In I CITY 1 1 0 0 S• tA&i V\ Sv-,e.ek- a T E , G 5 3 3 too II. TANK DESCRIPTION 432 433 T NK CONFIGURATION:THIS TANK IS 434 TANK ID# TANK MANUFACTURER 1.A STAND-ALONE TANK Compine ow Mai tOf each ❑ 2.ONE 1N A COMPARTMENTED UNIT comt>ornnecn 1e the x,437 DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT b� 2 C,0-m- - :: III. TANK USE AND CONTENTS 439. TANK USE la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc.AVIATION FUELING ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(tududes Used Oa) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25221.5(43) ___ ❑ 6.OTHER GENERATOR FUEL_ _ 95 UNKNOWN ❑ 99.07 HER(Specify): 440 CONTENTS PETROLEUM: iia.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED [1 3.DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS 440&___.-_.-._ -._.___.. E] 8.PETROLEUM BLEND FUEL 9.OTHER PETROLEUM(Specify): --- - NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 440b ❑ 11.OTHER NON-PETROLEUM(S IV. TANK CONSTRUCTION 443. TYPE OF TANK _._.-__--- 1.SINGLE WALL 2.DOUBLE WALL 95 U�KNOWN, _ _ ---_._........---...----------------- PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.INBLADDER 4a4a ------ -_ 7.STEEL+[NTE AL LINING - -._._Q95.0 ❑ 99 OTHER(Specify): ----- 445. SECONDARY CONTAINMENT [] 1.STEEL3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 4452 ❑ 90_.NONE ❑ 95.UNKNOWN ❑99_.OTHER(Specify): ase. ----- OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARM-.S 2.BALL FLOAT ❑ 3.FILL TUBE SHUT OFF VALVE 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION E UIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION 460 PIPING CONSTRUCTION - L SINGLE WALL 2_DOUBLE WALL _(_99.OTHER -._____.-•--.._-__-__....____....------- --- - _--_�.--_-�-_.� 438. SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR 2636(e 3 -- PRIMARY CONTAINMENT ❑ 1.STEEL - .4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464a _ ❑ 90.NONE_ _ -0 95.UNKNOWN_-Q 99.OTHER(Specify)_ SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ IQ RIGID PLASTIC 4640 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(S ci ): 464d PIPING/TURBINE CONTAINMENT SUMP TYPE X I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90 NONE VI. VENT,VAPOR RECOVERY (VR) AND RISER/FILL PIPE PIPING CONSTRUCTION 464e VENT PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify)_ 464E --_---- --------------...-- ----...---------------- - -_-_.__ VENT SECONDARY CONTAINMENT [3 1.STEEL [3 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 464fl. - --- VR PRIMARY CONTAINMENT ❑ I.STEEL �K4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464 1- --- VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC b(90.NONE ❑ 99.OTHER(Specify): 464hl. T---._.....-------.._..----._...----- 4641. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL Vqo.NONE RISER PRIMARY CONTAINMENT 'R 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 9o.NONE ❑ 99.OTHER(Specify): 4641 RISER SECONDARY CONTAINMENT ❑ 1-STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC g9O.NONE ❑ 99.OTHER(Specify): 464k1 FILL COMPONENTS INSTALLED l SPILL BUCKET 1&3.STRIKER PLATFJBOTTOM PROTECTOR 4.CONTAINMENT SUMP aste c. VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL [ 2.DOUBLE WALL ❑ 3.NO DISPENSERS _0_90.NOME --- 469& -- ------ - - ------- --- - 469b. CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99 OTHER(Specify) 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT V6.ISOLATION us 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 "JPPLICANT SIGNATURE 1 DATE 1472 AME(print) KULDEE n C. Su�MA, alt APPLICANT TITLE rAP-w\6M ' LLL- UPCF UST-B Rev.(12/2007)-1/2 Y www.unidocs org