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WIFIED PROGRAM CONSOLIDATED F p1 UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. For 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 El5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE C.UST PERMANENT CLOSURE ON SITE El8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 411, DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 BUSINE S NA YE(Same as FACILI Y NAME o DBt-Doing Business As) 3 ' '2 04J BUSINRSSSIT7E ADD103 CITY 104 II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TK CONFIGURATION: THIS TANK IS 434 /�� /y 1.A STAND-ALONE TANK o r,v�S 3 ❑2.ONE IN A COMPARTMENTED UNIT. �p Complete one page for each com artment in the unit. DATE UST SYSTEM INSTALLED 435 TANK CA2ACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 Qdt� III.TANK USE'AND CONTENTS TANK USE ❑ Ia.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ 1c.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 6 99.OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ 1b.PREMIUM UNLEADED 440 f3.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 r_ IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL W 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADD R 444 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN (Specify): 444a SECONDARY CONTAINMENT 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 9-99,OlQ.Qb;& 95.UNKNOWN ❑99.OTHER(S ecify): FZIM, OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUIBE SHUT-OFF VALVE 451 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED W2.DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ .GRAVITY Z 3.CONVENTIONAL SUCTION 2636(aX3)I 458 PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS 1X8.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/TURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY,(VR)AND RISER IULL;PIPE PIPING CONSTRUCTION,,sI. = VENT PRIMARY CONTAINMENT L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 464f1 VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464 g I VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464i. RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464] 464'I RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464kl FILL COMPONENTS INSTALLED 1.SPILL BUCKET R ❑ 4.CONTAINMENT SUMP '.x 451 a-c VII.UNDER DISP ER NT;(UDC) ,' ` k CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS 0 K 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) "t 469b-c VIII. CORROSION PROTECTION ` STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION C_: 448. IX. APPLICANTSIGNATURE CERTIFICATION: I certify that this UST system is compatib a with the hazardous substance stored and that the information provided herein true,accurate, and in full compliance with legal requiVqfents. 17 APPLICANT SIGNATU DATE / '! 470. 1� APPLICANT NAME(print) 471. APPLICANT TITLE 472. UPCF UST-11-1/2 Rev.(12/2007)