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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) T"'Er OF ACTION (Check one item only. Fora ST closure or removal,complete only this section and Sections I,If,III,IV,and IX below) 430. *' .1.NEW PERMIT ((3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION Lj TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4304 1 DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) - - o 1' BUSINESS NAME(Same as Facility Name or DBA-DoinBusiness As) 3. ��zC:Q1c�63. Gas S � BUS�I`jF S; �l�lN'S F� P DRES U13. BUSINE$$ O l v toa. l II. TANK DESCRIPTTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434• s ❑ 1.A STAND-ALONE TANK Complete one page for each -�- "�Jrp V V 4 2.ONE IN A COMPARTMENTED UNIT compartment in the unit DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OE-C-AA4�ARTMENTS IN THE UNIT 437. 71, 6 bG III. TANK USE AND CONTENTS TANK USE U4..MOTOR VEHICLE FUELING C] Ib.MARINA FUELING ❑ lc.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 ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED EHb.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 4404 NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ L SINGLE WALL &-2.DOUBLE WALL ❑ 95.UNKNOWN _ 443. 444. PRIMARY CONTAINMENT STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER - - -❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4444 SECONDARY CONTAINMENT ❑ 1.STEEL �.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ---�-95_UNKNOWN ❑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 WALL-®'2_DOUBLE WALL ❑ 99.OTHER 460' SYSTEM TYPE _ _ ICI t.PRESSURE ❑ 2 GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] -- 458_ _ PRIMARY CONTAINMENT ❑ 1 STEEL Er4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90_NONE- ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464& SECONDARY CONTAINMENT ❑ 1.STEEL N r4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. _❑ 90.NONE ❑ 95.UNKNOWN_ _❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE S-"I,SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I.STEEL V4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464el. - ----------------.._...... ------ 464f. VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC 0'90.NONE ❑ 99.OTHER(Specify): 464fl. VR PRIMARY CONTAINMENT ❑ L STEEL 6d'4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464 VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC U*90.NONE El99.OTHER(Specify): g64hj VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 464i.__.-464j.... RISER PRIMARY CONTAINMENT SKI.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464.1. RISER SECONDARY CONTAINMENT ❑ 1.STEEL [j4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): g64kj FILL COMPONENTS INSTALLED W.SPILL BUCKET [,3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a-c. VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE _ _1.SINGLE WALL - -_ ❑ 2.DOUBLE WALL_ Q 3.NO DISPENSERS ❑ 90_NONE 469& - -- -- 469b. CONSTRUCTION MATERIAL [{Y L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT e'6.ISOLATION 448. IM APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accura nd in fuK96mpliancg with 1 uirements. APPLICANT SIGNATURE �'C' V DATE /b Q 9' azo. 'n 471. ( //j 4r_. APPLICANT NAME(print) Nn � �� r'j 1J� /ter APPLICANT E I V UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org Effective 01/17/08