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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANKE::: / t� OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,III,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 ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) I BUS SS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 7Z' BUSINESS SITE ADDRESS. t*L U �� 103 CITY � (uCK � � 104 II.TANK DESCRIPTION TANK ID# ` L/ 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 TAL /'� J I S b �- ❑L A STAND-ALONE TANK U /I C"� �C S Gfl'2.ONE M A COMPARTMENTED UNIT. Co fete one page for each corn artment in the unit. DA ECJ T SY TE INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF CO TMENTS IN THE UNIT 437 C f Z 000 M.TANK USE AND CONTENTS TANK USE Lf!�.la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.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.OTHERS OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ ic.MIDGRADE UNLEADED Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b IV. TANK.CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 97.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL Ak3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION I.AUDIBLE @ VISUAL ALARMS 2.BALL FLOAT A3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ L STEEL 0-4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL i FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL fiK4.FIBERGLASS 10.RIGID PLASTIC 90.NONE D 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL V.4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f VR PRIMARY CONTAINMENT ❑ 1.STEEL &4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464g 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE M 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT 1.STEEL K 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE C3 99.OTHER(Specify) 4641, 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER C NTAR MENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL din.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL 1.STEEL IR 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b-c 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 com ith al requirements. °j n `/ APPLICANT SIGNATURE / DATE © 470. APPLICANT NAME(print) _ an. APPLICANTTITLE �/� 471. �] UPCF UST-B-112 V � � �[ L�l 'D 13 Rev.(12/2007) (,(y.