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l UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK N O C4'-_'5' OPERATING PERMIT APPLICATION-TANK INFORMATION (one form per UST) TZnTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,A III,IV,,and IX below) 430. 10L NEW PERMIT ❑ 3.RENEWAL PERMIT C35.CHANGE OF INFORMATION n_6-TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4307 1 DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) - - � �'> 1' BUSINESS NAME n E(�S_a,Ir�e Is- Ngtne or DSA-Doing fi i iness As) �; 3' BUSINES SIIT,E�AD�`D(RESP (� s 103. BUSINESSAI C / - 104 1 t � �-L fr l� sr �Iemt � f? J II. TANK DESCRIPTION TANK ID# 432. TANK MANJJFACTURER 433. TANK CONFIGURATION:THIS TANK IS 7347 T 1.A STAND-ALONE TANK Complete one page for each -T �r ' C v ❑ 2.ONE INA COMPARTMENTED UNIT �Pa*hnent in the unit. DATE UST SYSTEM INSTALLEp 435. TANK CAPACITY IN GALLON 436. NUMBER OF CO TMENTS IN THE UNIT 437. 01 �t 10 On 0 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(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(.)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439& CONTENTS PETROLEUM: ®�Ca.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS _ ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440& ......._ NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL DOUBLE WALL ❑ 95.UNKNOWN 443' -- - --------- - ---------------------------- -------- ------------------ 444. PRIMARY CONTAINMENT U/1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444& SECONDARY CONTAINMENT ❑ 1.STEEL QS.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHERSPecfi): 445& _.... - OVILL ERFPREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT KI-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_WALL 2.DOUBLE WALL- (] 99.OTHER _ _____ _______ ___- 460. --- ----- --- -- ----- -- SYSTEM TYPE _ - �}L PRESSU_R_E ❑ 2.GRAVITY -❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(x)(3)] _458. PRIMARY CONTAINMENT C] L STEEL 11-4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. -- -0-90_NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464& SECONDARY CONTAINMENT ❑ L STEEL S-4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. _ ❑ 90.NONE_ ❑ 95.UNKNOWN- ❑-99_OTHER(Specify): 464c. PIPING/TURBINE CONTAINMENT SUMP TYPE Sall.SINGLE WALL C] 2.DOUBLE WALL E] 90.NONE 464x VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION 64 VENT PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464e1 --- -- ------------ 464E VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC g0.NONE ❑ 99.OTHER(Specify): 4640. - ---------_ ._..-------------- - - 464g. VR PRIMARY CONTAINMENT ❑ 1.STEEL S],4.FIBERGLASS ❑ 10.RIGID PLASTIC '10.NONE ❑ 99.OTHER(Specify): 464 1. --------- - ------........---- ------ ---- ------- VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC la-90.NONE ❑ 99.OTHER(Specify): 464hl. -- ---- ------. _ _-- - -- --- VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL (}'90.NONE 4 ' --- 46th RISER PRIMARY CONTAINMENT MA.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464.1. RISER SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑-90.NONE ❑ 99.OTHER(Specify): 464kj FILL COMPONENTS INSTALLED U.SPILL BUCKET []"3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451 ac. VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL 4697 _ ----- ------ -- -- -------- --- -�3_NODISPENSERS....._._-0 90_NONE 469b. CONSTRUCTION MATERIAL Q L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this US ystem is compatible with the hazardous substance stored and that the information provided herein is true, accurate and in full liance with legal requimments. APPLICANT SIGNATURE w_C' r DATE �/ azo. APPLICANT NAME(print)PH P eh W f ��/ p Ir 12 771. APPLICANT TITLE vI W a/rg 472. UPCF UST-B Rev.(12/2007)-1/2 /�www.unidocs.org �y w Effective 01/17/08