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AdEL UMMED PROGRAM CONSOLIDATED FOR72F UNDERGROUND STORAGE TANK 1 / OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections I,II,Ill,IV,,and IX below) 430. ❑ 1.NEW PERMIT 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE �-7.UST PERMANENT CLOSURE ON SITE El 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430- 1 DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) A 1-10 OO - (o BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) NUN S R. E'1 kXLO AM M -. JS IL S e.NTE1L k 5 S tN " BUSINESS SITE ADDRESS 103• CITY 104 U00 S- MAUA SIMEET VAN C-/A II. TANK DESCRIPTION TANK ID#eMqrjp(p�jp✓� 432• TANK MANUFACTURER 433. TANK CONFIGURATTON:THIS TANK IS 434. U H L E A E D X ER K E S 1.A STAND-ALONE TANK Complete one page for each 2.ONE IN A COMPARTMENTED UNIT compattmmt in the unit. DATE UST SYSTEM INSTALLED 435• TANK CAPACITY IN GALLONS 436• NUMBER OF COMPARTMENTS IN THE UNIT 437. 141 ql 101 2c 0 b III. TANK USE AND CONTENTS TANK USE Ia.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)I ❑ 6.OTHER_GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a. CONTENTS PETROLEUM: 79 Ia.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 f DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify)_ tea'..__.._____ 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 ,r PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. _ ❑ 7.STEEL+INT _AL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444a. SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED -445. _ ___ _ ❑ 90.NONE 1-] 95.UNKNOWN ❑99.OTHER(Specify): 445a. OVERFILL PREVENTION_---X1.AUDIBLE&VISUAL ALARMS A2.BALLFLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE asz. 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION r PIPING CONSTRUCTION ❑ 1.SINGLE WALL _ 2.DOUBLE WALL ❑ 99.OTHER 460• SYSTEM TYPE - _ 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION L23 CCR§2636(a 3) ass. 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 464b. _❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. PIPING/IIJRBINE CONTAINMENT SUMP TYPE X 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644. VI. VENT, VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL19 4.FIBERGLASS [:110.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4644e 1. VENT SECONDARY CONTAINMENT ❑ 1.STEEL [14.FIBERGLASS [310.RIGID PLASTIC X90.NONE ❑ 99.OTHER(Specify): 464ri. VR PRIMARY CONTAINMENT V❑ 1.STEEL 4.FIBERGLASS [110.RIGID PLASTIC ❑ 90.NONE [199.OTHER(Specify): 46446. VR SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE [199.OTHER(Specify): 464hi. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 464t. RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464] -RISER SECONDARY CONTAINMENTT ❑ 1.STEEL [14.FIBERGLASS [I10.RIGID PLASTIC 90.NONE [199.OTHER(Specify): 464ki FILL COMPONENTS INSTALLED 1.SPILL BUCKET jg 3.STRIKER PLATEBOTTOM PROTECTOR 4.CONTAINMENT SUMP 451a-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a. CONSTRUCTION MATERIAL ❑ 1.STEEL X4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4669C. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES ❑ 4.Ev1PRESSED 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 DATE r� 21 1 I 470. APPLICANT NAME(print) et? C - SH AP'M A 71 APPLICANT TITLE C E a 472 TTPrV rrr 0 0.... 111 non-IN i n