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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. For a U T closure or removal,complete only this section and Sections 1,11,111,IV,and IX below) 430. 1.NEW PERMIT 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: 4306. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Sa e s acility Name or DBA-Doing Business As) r. 3• \,t,\ 'PT��r� CAt\+ $ LI tA4A tv� BUSINESS SITE ADDRESS 103. BUSINESS E CITY �1\ � C- (L w J29 - s�cle ) o IV 1#� Ci II. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. /A �n ❑ 1.A STAND-ALONE TANK Complete onepage for each 4 K► l [� 61/tONE INA COMPARTMENTED UNIT cmPartmmtinthe wit DATE YST SYSTEM INSTALL 435. TANK CAPACITY GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. b o 00e 2 III. TANK USE AND CONTENTS TANK USE a.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(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN _ ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440• Q,V DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS �J 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT ®"I.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL Mail.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445- 0 90.NONE ❑ 95.UNKNOWN [199.OTHER(Specify): 445a. OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT (r3.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 all.DOUBLE WALL ❑ 99.OTHER 460. SYSTEM TYPE 91.1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458. PRIMARY CONTAINMENT ❑ 1.STEEL Nr4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN _ ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ I.STEEL Q-4.FIBERGLASS ❑ 8 FLEXIBLE ❑ 10.RIGID PLASTIC 4646. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a - -..__......----- ---------.._...------------------......---- ------ - --- ----- PIPING/TURBINE CONTAINMENT SUMP TYPE SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL 2'4.FIBERGLASS [I10.RIGID PLASTIC C190.NONE [199.OTHER(Specify): 464cl _------------._--------_....._.----------- 464E VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC &K90.NONE ❑ 99.OTHER(Specify): 464U ...-----....------ -- ------ -------------- - --._......---- -- ........-- - --- -------._....._..-- -- --- ----- - VR PRIMARY CONTAINMENT ❑ L STEEL &r4.FIBERGLASS C] 10.RIGID PLASTIC ❑ 90.NONE [199.OTHER(Specify): 464 VR SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC [Y90.NONE ❑ 99.OTHER(Specify): 464h1. VENT PIPING TRANSITION SUMP TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 4M` _.. - -......_... -- -- ---- a6a]. RISER PRIMARY CONTAINMENT L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464 1 RISER SECONDARY CONTAINMENT 0 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 464k1 FILL COMPONENTS INSTALLED .SPILL BUCKET 01-3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c. VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL C] 3.NO DISPENSERS ❑ 90.NONE 469& -..........--...... ---------------- CONSTRUCTION MATERIAL 11-1.STEEL [34.FIBERGLASS ❑ 10.RIGID PLASTIC [199.OTHER(Specify) 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 0'6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that is UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate 1, full com fiance with IMI Eqlorements. APPLICANT SIGNA DATE /D /J� O azo. APPLICANT NAME M / t `/.9.4e v/ %71' APPLICANT TITLE aw AI (� 472. UPCF UST-B Rev.(12/2007)-1/2 (J ww/w.unidocs.org !- Effective 01/17/08