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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PE IT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. Foran permanent closure or removal,complete only this section and Sections 1,II,III,IV,and IX below) 430 [11.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 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ 1 - 1 1 l BUSINESS NAME Same as FACILITY NAME or DBA-Doing Busin s 3 BUSINESS S E ADPJJESS�y) r �.` - _ 103 CITY l ()E> t C �� loa `f y II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 S-r.-A STAND-ALONE TANK /X•V f� !� ❑2.ONE IN A COMPARTMENTED UNIT. Complete one pagc for each compartment in the unit. DATE CrSTSY TF}�I�IVST LED 435 TANK CAPACITY IN GAL NS 436 NUMBER OF COMPARTMENTS INN UNIT 437 It "� 1-11III.TANK USE AND CONTENTS TANK USE OKa.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCTS ORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERATO L ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: a.REGULAR UNLEADED ❑ la MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED �o ❑ 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): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ L SINGLE WALL 072"IJOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL akrFIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LG ❑ 95.UNKNOWN ❑ 9j.OTHER (Speci ): 444a SECONDARY CONTAINMENT [jL STEEL FIBERGLASS ❑ 6.EXTERIOR MEMBRAPE LINER ❑ 7.JACKETED 445 NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify), I 445a OVERFILL PREVENTION PVUDIBLE&VISUAL ALARMS 2.BALL FLOAT FILL TUBE SHUT-OFF VALVE 452. W.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 PRESSURE ❑ 2. VITY ❑ 3.CONVENTIONAL SUCTION [34.SAFE SUCTION[23 CCR§2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 9 .UNKNOWN ❑ 99.OTHER(Specify): `tea SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGITURBINE CONTAINMENT SUMP TYPE EFI.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECOVER )AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT L STEEL 4.Ft RGLASS ❑ 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464E 46411 VR PRIMARY CONTAINMENT ❑ 1.STEEL FIBS LASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464g 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 10. ID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 1.SINGLEWALL 2.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS U 10.RIGID PLASTIC 90.NONE Lj 99.OTHER(Specify) 464j I RISER SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT CONSTRUCTION TYPE ❑ 1.SINGLE WALL DOUBLE WALL ❑ 3. DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ L STEEL 4.FIBERGLASS EY10.RIGID PLASTIC ❑ 99. HER(Specify) 469bbc VIII. CORROSION PROTECTION 448. STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 4 IX.'APPLICANT SIGNATURE CERTIFICATION: I certify UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in f m H nce with legal requirements. ` 470. DATE APPLICANT SIGNATURE ^ APPLICANT N nt)fl L��- �A t Lam_ a7L APPLICANT TITLE A L-for-.7 f 472. l�r�LGI�J�Jhrwlao�n. �r .G•,Le 4s"L t� 4�4 �N ��i3/�2 UPCF UST-11-1/2 Rev.(1212007)