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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) <br /> TYPE OF ACTION (Check one item only. Fo an UST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) <br /> 430 <br /> ❑ 1.NEW PERMIT 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL 4306 <br /> DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) - - <br /> 3 <br /> BUSINESS NAME(Same as/f4CILITY NAME or DBA-Doing Business As) <br /> C`+ V al Z 104 <br /> BUSINESS SITE ADDRESS 103 CITY <br /> II.TANK DESCRIPTION <br /> 432 'TAUT{MANUFACTURER 433 TANK CONFIGURATION: T ms TANK IS 434 <br /> TANK ID# <br /> S [11.ASTAND-ALONE TANK <br /> 74ATE <br /> l 5 3 _ 9 2.ONE IN A COMPARTMENTED UNIT. <br /> C Tete one a for each com tithe,mitDST SYSTEM INSTALLED 435 TANK C�EACITY IN GALLONS 436 NUMBER OF COMP S IN THE UNIT <br /> 437 <br /> � m <br /> III.TANK USE AND CONTENTS <br /> TANK USE )Z la.MOTOR VEHICLE FUELING [IIb.HABENA FUELING ❑ <br /> lc.AVIATION FUELING 439 <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] 4394 <br /> ❑ <br /> 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 440 <br /> CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ 1b.PREMIUM UNLEADED <br /> 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS 440a <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 4406 <br /> ❑ <br /> 11.OTHER NON-PETROLEUMM S <br /> IV. TANK CONSTRUCTION 443 <br /> TYPE OF TANK ❑ 1.SINGLE WALL 19 2.DOUBLE WALL ❑95.UNKNOWN 444 <br /> PRIMARY CONTAINMENT ❑ I.STEEL R 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444a <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): aa5 <br /> SECONDARY CONTAINMENT ❑ 1.STEEL FIBERGLASS 136.EXTERIOR MEMBRANE LINER [37.JACKETED 4454 <br /> ❑ 90.NONE 95.UNKNOWN ❑99.OTHER(S ei ): 452. <br /> OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑1.SINGLE-WALLED al DOUBLB WALLED [199.OTHER 458 <br /> SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY r-13.CONVENTIONAL SUCTION [:14.SAFE SUCTION[23 CCR§2636(aX3)] 458 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL �(4.FIBERGLASS 118.FLE)aBLE ❑ 10.RIGID PLASTIC a6aa <br /> ❑ 90.NONE ❑ 95.UNKNOWN El 99.OTHER(Specify): 4646 <br /> SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464c <br /> ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): a64d <br /> PIPING/IURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL [12.DOUBLE WALL ❑ 90.NONE <br /> VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS 10.RIGID PLASTIC 0 90.NONE [3 99.OTHER(Specify) 464e <br /> 464el <br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS E] 10.RIGID PLASTIC [190.NONE [3464f 99.OTHER(Specify) 464171 <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99-OTHER(Specify) 464g <br /> 464 1 <br /> 464h <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464hl <br /> 2.DOUBLE WALL ❑ 90.NONE 464i. <br /> VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL a64i <br /> RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) �,t <br /> 464k <br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464k1 <br /> FILL COMPONENTS INSTALLED j5bl.SPILL BUCKET ❑ 3.STRIKER PLAWBOTTOM PROTECTOR 4.CONTAINMENT SUMP <br /> 451 a� <br /> VII.UNDER DISPENSER CONTAINMENT(UDC) <br /> 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a <br /> CONSTRUCTION TYPE 4696-c <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC El99.OTHER(S ) <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) [1ES <br /> 4.IMPRSED CURRENT 6.ISOLATION fig' <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify th t is UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, <br /> and in f om liance with 1 al r uirements. 470. <br /> APPLICANT SIGNATURE .L DATE <br /> /U I 1D <br /> ' 471. l a7z. <br /> APPLICANT NAME( APPLICANT TITLE <br /> lel J` <br /> Rev.(12/2007) <br /> UPCF UST-B-1/2 <br />