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3 3/ UNIFIED PROGRAM CONSOLIDATED FORM 'fll / UNDERGROUND STORAGE TANK / OPERATING PERMIT APPLICATION-TANK INFORMATION (one form per UST) TYPE OF ACTION (Check one item only. Foa ST closure or removal,complete only this section and Sections 1,11,111,IV,and IX below) 430. ❑ 1.NEW PERMIT 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION El 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 0 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: - 430a 1 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) F A - 0 p - °7 L`. �, BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. MAIN STREET Az2t0 AMPM - k ,fS EN?EPUK.SE LLC- BUSINESS SITE ADDRESS LC.BUSINESSSITEADDRESS 1°3. CITY '04 1100 5. Ma;v� ,ee�- IllA-NrEC-A , C-A 95 '33 -1- H. S 33 -}- II. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. u' }� n 1.A STAND-ALONE TANK Complete one page for each vTv L�'rY�+/ ��E S ❑ 2.ONE 1N A COMPARTMENTED UNIT compartment in the unit. DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. b`} 2a - III. TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.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: Ala.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL _❑ 9.OTHER PETROLEUM(Specify): 440L _ NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): "Ob. IV. TANK CONSTRUCTION TYPE OF TANK _ ❑ 1.SINGLE WALL DOUBLE WALL ❑ 95.UNKNOWN _ _,. 443 PRIMARY CONTAINMENT ❑ 1.STEEL 0,3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTEP9AL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL A3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION MI.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 ❑ LS WALL 2.DOUBLE WALL ❑ 99.OTHER 460. SYSTEM TYPE -MI.PRESSURE_ ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION_ ❑ 4.SAFE SUCTION X23 CCR§263 a 3) 458. PRIMARY CONTAINMENT ❑ 1.STEEL %4.FIBERGLASS ❑ 8.FLEXIBLE [310.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ I.STEEL �4.FIBERGLASS [18.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. _❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. PIPING/PURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT (3FIBERGLA 1.STEEL 4. SS ❑ 10.RIGID PLASTIC ❑ 90.NONE [399.OTHER(Specify): 4644el. VENT SECONDARY CONTAINMENT [31.STEEL ❑ 4.FIBERGLASS ❑ 10.RIG iD PLASTIC 90.NONE ❑ 99.OTHER(Specify): 464f]. - ---- VR PRIMARY CONTAINMENT [3 1. ❑1.STEEL FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE E399.OTHER(Specify): aha VR SECONDARY CONTAINMENT ❑ 1.STEEL [14.FIBERGLASS [310.RIGID PLASTT-C�90.NONE [199.OTHER(Specify): 464hl. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 'W90.NONE 464` RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4 j: RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Spedfy): 464 FILL COMPONENTS INSTALLED 1.SPILL BUCKET X 3.STRIKER PLATE/BOTTOM PROTECTOR W 4.CONTAINMENT SUMP 451e-c. VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.S[NGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS 90.NONE 469a. ' 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 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. APPLICANT SIGNATURE ` DATE3 lD 470.20 � APPLICANT NAME(print) V U j.©EEP C_ SK pd1,M k 471. APPLICANT TITLE N�e►Mha+ - L L.t, 472 UPCF UST-B Rev.(1212007)-1/2 www.unidocs.org