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2 <br /> %f**J-, I <br /> NIFIED PROGRAM CONSOLIDATED FOW7, <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) <br /> TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this sec on and Sections I,R,III,IV,and IX below) 430 <br /> ❑ E NEW PERMIT ❑ 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430' DATE EXISTING UST DISCOVERED: 43ob <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) <br /> BUSINESS NAME(Same as F CTY NAME rA-Doing Business As) 3 <br /> BUS S SIT ADDRESS 103 CITY C 104 <br /> IL TANK DESCRIPTION <br /> TANK ID# r // 432 TANK MANUFACTURER 433 <br /> �� 43j3 TANK CONFIGURATION: THIS TANK IS 434 <br /> ,,(� Q r.»P Y ,nom w`-"-Y 7• 0'2.ONE IN NI A-COMMPPAAR TANK <br /> COMPARTMENTED UNIT. <br /> ll� Complete me page ram cmWarunent m the m <br /> DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPART ENTS IN THE UNIT 437 <br /> pc�D <br /> III.TANK USE AND CONTENTS <br /> TANK USE a.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Ic.AVIATION FUELING 439 <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a <br /> CONTENTS PETROLEUM: 1&REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUMS 44ob <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 <br /> PRIMARY CONTAINMENT L STEEL,' ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 <br /> 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER S 444& <br /> SECONDARY CONTAINMENT ❑ 1.STEEL jV3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 <br /> 90.NONE ❑ 95.UNKNOWN ❑99.OTHER S 445a <br /> OVERFILL PREVENTION AUDIBLE&VISUAL ALARMS Lj 2.BALL FLOAT bl�FILL TUBE SHUT-OFF VALVE 452. <br /> 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑1.SINGLE-WALLED NZE.DOUBLE-WALLED ❑99.OTHER 460 <br /> SYSTEM TYPE L PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(a)(3)] 458 <br /> PRIMARY CONTAINMENT 1.STEEL JW4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS [I 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b <br /> ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464c <br /> PIPING/fURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d <br /> VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT IC L STEEL ^ 1.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464e <br /> 464el <br /> VENT SECONDARY CONTAINMENT ❑ L STEEL4.FIBERGLASS ❑ 10.RIGID PLASTIC JO 90.NONE ❑ 99.OTHER(Specify) 464f <br /> 464n <br /> VR PRIMARY CONTAINMENT L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4646 <br /> 464 1 <br /> VR SECONDARY CONTAINMENT ❑ L STEEL Q 4.FIBERGLASS ❑ 10.RIGID PLASTIC IQ 90.NONE ❑ 99.OTHER(Specify) 464h <br /> 464h1 <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL 19 90.NONE 4641 <br /> RISER PRIMARY CONTAINMENT L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC Lj 90.NONE Lj 99.OTHER(Specify) 4641 <br /> I <br /> RISER SECONDARY CONTAINMENT ❑ L STEEL L 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 464k <br /> 4641 <br /> FILL COMPONENTS INSTALLED tXLSPILLBUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a <br /> VII.UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ❑ 1.SINGLE WALL .DOL)BLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b-c <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448. <br /> IX. APPLICANT SIGNATURE x <br /> CERTIFICATION: I certik that this UST system i4 compatible with the hazardous substance stored and that the information provided herein is true,Is, ` <br /> and in rill compliance with leZal requirements. <br /> DATE �^ <br /> APPLICANT SIGNATURE hK v ( 1 <br /> ` APPLICANT NAME(print) V �/ /'_( � I 471 APPLICANT T E <br /> �� v /]j aaz. <br /> (3 (S a <br /> JUL 18 ?iiia b <br /> Rev. 12/2 <br /> UPCF UST-B-1/2 ( � <br />