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I ) IED PROGRAM CONSOLIDATED FOFqrSII �I Z UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form UST TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11,111,IV,and IX below) 430. ❑ 1.NEW PERMIT (13.RENEWAL PERMIT 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a- 1 DATE EXISTING UST DISCOVERED: 430b. I. FACILITY_ INFORMATION FACILITY ID#(Agency Use Only) _ L BUSINESS VAME(Same as Facility Name or DBA-Doing Business As) 3• ASt IAA(L BUSINESS SITE ADDRESS 103. 1 CITY 104. II. TANK DESCRIPTION TANK ID J# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. t I t V J c ❑ 2.ONE IN A COMPARTMENTED UNIT com1.A STAND-ALONE TANK partment ilete one nthe for each DATE LOST YS NSTO STALLED 435• TANK CA ACITQY IN; Tz GALLONS 436• NUMBER OF COM IN THE UNIT 4 V _ �_� III. TANK USE AND CONTENTS TANK USE Ia.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING Q Ic.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE 0 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)) ❑ 6.OTHER GENERATOR FUEL ...__❑ 95 UNKNOWN _ .._......._..._ ... ..._ ._ . ....._Q 99.OTHER(Specify): 439a. CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED 0 ib.PREMIUM UNLEADED 440. 3.DIESEL 0 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(S ci ): 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443.1 PRIMARY CONTAINMENT ❑ 6. I.STEEL .___......_ ❑ 3.FIBERGLASS _ _.. ....._._.._._... ._._ _.. INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444a. ---- ----.- __...- --_....__.- - - -- SECONDARY CONTAINMENT ❑ I.STEEL []p.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445• ❑ 90 NONE Q 95_UNKNOWN .Q 99.OTHER(Specify): 445a. OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT W3.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 WALL2.DOUBLE WALL ❑ 99 OTHER 460. SYSTEM TYPE 1 PRESSURE ❑_ 2.GRAVITY Q 3 CONVENTIONAL SUCTION _❑ 4 SAFE SUCTION[23 CCR§2636(a)(3)) 458. PRIMARY CONTAINMENT ' ] 1 STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. _ __ _ go. 0 NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464x. SECONDARY CONTAINMENT ❑ 1.STE1.EL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. _❑ go.NONE Q 95.UNKNOWN ❑ 99.OTHER(Specify)_ 464c. PIPING/TURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644. VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL W4 FIBERGLASS Q 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46444. 4644. VENT SECONDARY CONTAINMENT Q 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ®'90.NONE ❑ 99.OTHER(Specify): 46441. .. _. -__ _: _.... VR PRIMARY CONTAINMENT ❑ 1 STEEL W4 FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90.NONE Q 99 OTHER(Specify): 4644g. .. --- _ _ ........ . ... . . .. ..__.. __---- .--.-- ---____. _ _- .._ VR SECONDARY CONTAINMENT ❑ 1.STEEL [14.FIBERGLASS 1310.RIGID PLASTIC $90.NONE ❑ 99.OTHER(Specify): 464h. 464hl. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 464i. -.._..... --------- RISER ----RISER PRIMARY CONTAINMENT JR 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4641 RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ,W90.NONE ❑ 99.OTHER(Specify): 46441. FILL COMPONENTS INSTALLED SPILL BUCKET G'3.STRIKER PLATE/BOTrom PROTECTOR 4.CONTAINMENT SUMP 451a-c. ViI. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE - 1 SINGLE WALL 2 DOUBLE WALL ❑ 3 NO DISPENSERS ❑ 90 NONE 469a CONSTRUCTION MATERIAL 1.STEEL ❑ 4.FIBERGLASS Q 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b. -_ VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate and in full compliance with legal requirements. APPLICANT SIGNATU F DATE O r azo. APPLICANT NAME(print) 471' APPLICANT TITLE &pil/f 92�7e 472. UPCF UST-13 Rev.(12/2007)-1/2 www.unidocs.org