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Ll IFIED PROGRAM CONSOLIDATED FORIri 3 ►3 13 UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. Fora ST closure or removal,complete only this section and Sections 1,11,111,IV,and IX helow) 430. ❑ 1.NEW PERMIT 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE ❑ &UST REMOVAL DATE UST PERMANENTLY CLOSED: 4300 1 DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use IFIAI -1010 0 O D - 77 6 1. BUSINESS NAME(Same as Facility!Jame or DBA-Doing Business As) 3. MAIN S? BEET ArLLOAMPM - J S I<S E wm2-9MSES It IN L BUSINESS SITE ADDRESS 103. 1 CITY 104. 1100 5. MA44 S-TRF.ET MANTc.C-A CA 9533,-- 11. 533,-- II. TANK DESCRIPTION TANK ID# TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434• 9 r L M �`, ' `V4' �./.DE^ ��91*$, L �l.A STAND-ALONE TANK Complete one page for each tK. �1/` �J �„�rF+t ,J Lr ❑ 2.ONE IN A COMPARTMENTED UNIT compartment in the unit. DATE UST SYSTEM INSTALLED 435• TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437• 03 10, m -- III. TANK USE AND CONTENTS TANK USE I a.MOTOR VEHICLE FUELING ❑ I b.MARINA FUELING ❑ 1 c.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC 525281.5(c)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN -- -- ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ 1 a.REGULAR UNLEADED ❑ 1 c.MIDGRADE UNLEADED 1 b.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL 6.AVIATION GAS 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440x. - NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. [17.STEEL+INTERAL LINING ❑ 95.UNKNOWN [199.OTH ER(Specify): 4440. SECONDARY CONTAINMENT ❑ 1.STEEL "3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. [190.NONE 95.UNKNOWN ❑99.OTHER(Specify): 4458. OVERFILL PREVENTION f 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT [13.FILL TUBE SHUT-OFF VALVE 452 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION p 1.SINGLE WALL 2.DOUBLE WALL ❑ 99.OTHER _- -__- _ _ -- - 460. SYSTEM TYPE1.PRESSURE ❑ 2.GRAVITY El 3 CONVENTIONAL SUCTION El 4.SAFE SUCTION[23 CCR§2636(8 3) 458. PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS [:18.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE _ 95.UNKNOWN ❑ 99.OTHER(Specify): 4648 SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. ❑-90..NONE _-- -[1 95.UNKNOWN- C1 99.OTHER(Specify): 464c. PIPING/TURBINE 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 [11.STEEL 4 El [1464e. FIBERGLASS 10.RIGID PLASTIC- 90.NONE ❑ 99.OTHER(Specify): 464el. 464f. VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC t<90.NONE ❑ 99.OTHER(Specify): 464n 464g. VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464 1. -- -------- 464h. VR SECONDARY CONTAINMENT - ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 3K90.NONE ❑ 99.OTHER(Specify): 464hl. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL19 90.NONE 464` 464j. RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464 1 RISER SECONDARY CONTAINMENT [01.STEEL [34.FIBERGLASS [I10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 464k1. FILL COMPONENTS INSTALLED 1.SPILL BUCKET W.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 45la-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE_ 1.SIN_G_LE WALL __ 0_2.DOUBLE WALL_ ❑ 3.NO DISPENSERS _❑_90.NONE 469a. CONSTRUCTION MATERIAL - ❑ 1.STEEL 19 4.FIBERGLASS [310.RIGID PLASTIC [:199.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 heteilt true, accurate,and in full compliance with legal requirements. L,;, ...9 APPLICANT SIGNATURE DATE 470. s APPLICANT NAME(print) Kv1,OE E P r-. S H OAM A 471. APPLICANT TITLE E 472.