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IFIED PROGRAM CONSOLIDATED UNDERGROUND STORAGE TANK 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 X 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: 430b TANK USE x la. 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)] ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439a CONTENTS PETROLEUM: x la. REGULAR UNLEADED ❑ lc. MIDGRADE UNLEADED ❑ lb. PREMIUM UNLEADED 440 [13. 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 (Specifv): 440b TYPE OF TANK ❑ 1. SINGLE WALL x 2. DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1. STEEL X 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 ❑ 7. STEEL+ INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1. STEEL X 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99, OTHER (Specify): 445a OVERFILL PREVENTION ❑ 1. AUDIBLE & VISUAL ALARMS ❑ 2. BALL FLOAT x 3. FILL TUBE SHUT-OFF VALVE 452. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT PIPING CONSTRUCTION ❑ 1. SINGLE -WALLED x 2. DOUBLE -WALLED ❑ 99. OTHER ❑ 10. RIGID PLASTIC 460 SYSTEM TYPE x 1. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR §2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ 1. STEEL X 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER(Specify): ❑ 10. RIGID PLASTIC 464a SECONDARY CONTAINMENT ❑ L STEEL x 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464b ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): ❑ 10. RIGID PLASTIC 464c PIPINGITURBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE 464d VENT PRIMARY CONTAINMENT ❑ 1. STEEL x 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1. STEEL x 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464f 464£1 VR PRIMARY CONTAINMENT ❑ 1. STEEL X 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 4648 464g I VR SECONDARY CONTAINMENT ❑ 1. STEEL X 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE ❑ 1. SINGLE WALL x 2. DOUBLE WALL ❑ 90. NONE 4641. RISER PRIMARY CONTAINMENT x 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 4641 464' 1 RISER SECONDARY CONTAINMENT ❑ 1. STEEL x 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464k 464k1 FILL COMPONENTS INSTALLED x 1. SPILL BUCKET x 3. STRIKER PLATE/BOTTOM PROTECTOR x 4. CONTAINMENT SUMP 45la-c SII. JND R Dt PE 9 CONTAINMENT'(UDC) CONSTRUCTION TYPE X 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 469a CONSTRUCTION MATERIAL ❑ 1. STEEL x 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specifv) 469b -c STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION 448. 1 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 SIGNATUR DATE i 470. -I APPLICANT NAME (print) Dulcinea Covan 471.APPLICANT TITLE Compliance Manager 472. UPCF UST -B - 1/1 Rev. (12/2007)