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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 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: 431a DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 BUSINESS NA c�jmas FACI ITI Y NAME or DBA-Doing Business As) 3 BUSINESS SITE ADDRESS 103 CITY / 104 II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 /7 21.A STAND-ALONE TANK R.��J [12.ONE IN A COMPARTMENTED UNIT. Complete one page for each compartment in the wit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 lei q / Q0-g, 1 III.TANK USE AND CONTENTS TANK USE QT 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 ❑ 92.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 ❑ l 1.OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL gr2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ L STEEL Er3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ L STEEL 21.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S i ): 445a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.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 [12.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE .PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(ax3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL 914.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE 01.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAP5 RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION" VENT PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC C3 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC Cr9O.NONE ❑ 99.OTHER(Specify) 464f 464f1 VR PRIMARY CONTAINMENT Rr 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 2M.NONE ❑ 99.OTHER(Specify) 4646 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ L SINGLE WALL 2.DOUBLE WALL 0.NONE 4641. RISER PRIMARY CONTAINMENT a L STEEL ❑ 4.FIBERGLASS Lj 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464] 464'1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC 0.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED L SPILL BUCKET al.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE U11.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE ° 469a CONSTRUCTION MATERIAL L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) '' "469bc VIII. CORROSION PROTECTION' STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION '®` " 448 IX. APPLICANT SIGNATUREA4 CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true oeeurate, and in full com P fiance with legal requirements. APPLICANT SIGNATURE DATE 1/7/Z p /� azo. APPLICANT NAME(print) 1 ^ 471' APPLICANT TITLE 72' UPCF UST-B-1/2 Rev.(12/200)