COMPLIANCE INFO_2007-2012 - Laserfiche WebLink

Home Browse Search

?Lt%0Jl elt UNIFIED PROGRAM CONSOLIDATED FO 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 ❑ L 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: 430flI DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ 1 - 11 -71124 71 1 BUSINES NA Same as FACtLM NAME or Dj1 ingA ess As) 3 Jy BUSINF�SS S ADDRESS 103 CITY 104 II.TANK DESCRIPTION TANK ID# 432 THANK MANUFACTURER z 433 TANK CONFIGURATION: THIS TANK IS 434 t /yf l 1 j' �r'4 C��4'('A_- rAi 1❑1.A STAND-ALONE TANK ` ` J V L / 1 l ___`��-771 C2.ONE INA COMPARTMENTED UNIT. oA ete orw for ewh comparWxW in the oruL DATE US .SYS TALLED 435 TANK C! "Li GALLONS 436 NUMBER OF MPARTMENTS IN THE UNIT 437 III.TANK USE AND CONTENTS TANK USE la MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(lndudes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC$25281.5(c)I ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ I.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 '&'A.DIESEL ❑ 5.JEf FUEL ❑ 6.AVIATION GAS '1511i.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUMS 44ob IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT14 1.STEEL ❑ 3.FIBERGLASS [16.INTERNAL BLADDER 444 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER S 444a SECONDARY CONTAINMENT ❑ 1.STEEL X3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER S 445a OVERFILL PREVENTION 11 1.AUDIBLE 8c VISUAL ALARMS ❑ 2.BALL FLOAT ja 3.FILL TUBE SHUT-OFF VALVE 452. 04.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED UL2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)1 458 PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL 19 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGITURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVE Y(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE El 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL 1.FIBERGLASS ❑ l0.RIGID PLASTIC 18'90.NONE ❑ 99.OTHER(Specify) 44aft VR PRIMARY CONTAINMENT 1.STEEL i.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464 l VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 1.SINGLEWAL ❑ 2.DOUBLE WALL 90.NONE �i RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS Lj 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 46 j RISER SECONDARY CONTAINMENT 1.STEEL L FIBERGLASS 0 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464k 4641 FILL COMPONENTS INSTALLED 1.SPILL BUCKET ❑ 3.STRIKER PLATE(BOITOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL a2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER S ) 469b-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448. IX. APPLICANT SIGNATURE ,u CERTIFICATION: I certio that this UST system is compatible with the hazardous substance stored and that the information provided herein is tiniei accurate, and in ll compliance With legal requirements. 430. DATEAPPLICANT SIGNATU _ 4r4VlAPPLICNTTLE APPLICANT NAME(print) �T_V T/ a'tj JUL 18 til UPCF UST-13-1/2 Rev.(luto A