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L r UNIFIED PROGRAM CONSOLIDATED FORM " UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. For an U anent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 430 ❑ I.NEW PERMIT RENEWAL PERMIT [1 5.CHANGE OF INFORMATION C] 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 431a DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ I BUSINESS NAME(Same as FACILITY NAME or DB -Doing Business ) 3 BUSINESS SITE ADDUSS 103 CITY Q nV 1 C II- Gt �� 104 MAIt/11/ Sr 12�C- 1 � II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 i- 0:-s- : ❑I.A STAND-ALONE TANK ?c �cx moi , . Complete one page for each compartment in the writ. DATE usT SYSTEIvT INSTALLED 435 TANK CAPACITY IN G�ALLLONS 436 NUMBER OF COMPARTMENTS IN U� 437 III.TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ lb.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.OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED D U 9 FE-ADED jallb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS CN� - ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (specify): (1J� 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL EV2.2BLEWALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL IBERGLASS ❑ 6.INTERNAL BLADDE 444 [37.STEEL+INTERNAL LIN [195.UNKNOWN ❑ 9.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL IB ❑ 6.EXTERIOR MEMB NE LINER ❑ 7.JACKETED 445 Of9r,NONE ❑ 95.UNKNOWN [199.OTHER(S if):I 445a OVERFILL PREVENTION I.AUDIBLE&VISUAL ALARMS 2,BALL FLOAT 91 3.FILL TUBE SHUT-OFF VALVE 452. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCTJWASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 01,SINGLE-WALLED UBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE KrI.PRESSURE ❑ RAVITY [13.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE 1125;UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL Er 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4616 ❑ 90.NONE ❑ 9L UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVER )AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ L STEEL UPI.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 464t1 VR PRIMARY CONTAINMENT ❑ L STEEL .FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL FIBERGLASS 10. ID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE C3 1.SINGLE WALL .DOUBLE WALL90.NONE 4641. RISER PRIMARY CONTAINMENT 1.STEEL FIBE GLASS 10.RIGID PLASTIC 90.NONE Lj 99.OTHER(Specify) 4641 464'1 RISER SECONDARY CONTAINMENT 1.STEEL C&4.-FIBERGLASS 10.RIGID PLASTIC 90.NONE 13 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR 0 4,CONTAINMENT SUMP 45lac VII.UNDER DISPENSER CO AINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL UBLE WALL ❑ 3.NOD PENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL Uff.FIBERGLASS 10.RIGID PLASTIC ❑ 99.OT R(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 th t this UST system is compatible with the hazardous substance stored and that the information provi herein is true,accurate, and In fu fiance with legal requirements. APPLICANT SIGNATURE DATE j Q azo. APPLICANT NAME(print) 1' APPLICANT TITLE 472. 4WU4'0 r A44 d}+ q'S2 # 44 t UPCF UST-B-1/2 �Z Rev.(12/2007)