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7/ IED PROGRAM CONSOLIDATED FO UNDERGROUND STORAGE TANK Z OPERATING PERMIT APPLICATION-TANK INFORMATION (One foA per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections I,A!l!,!I,and!X below) 430. ❑ 1.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: 430- 1 DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ -7 1. BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3• �+ S . i te w2 BUSINESS SITE ADDRESS 103• CITY 104. Stiof( l Writ-aUSV R-A 103. n f II. TANK DESCRIPTION _. TANK ID# 432. TANK MA FACTURER 433. ?2. K CONFIGURATION:THIS TANK IS 434. T U E A STAND-ALONE TANK Complete one page for each (� IIT "" V(/ ONE IN A COMPARTMENTED UNIT compartment in the unit. DATE UST SYST M IN A LED 435• TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. ? 12-4000 III. TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING (3lb.MARINA FUELING ❑ lc.AVIATION FUELING 439. 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§2525 1.5(c)] _❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a. CONTENTS PETRO LE �UM. la.REGULAR UNLEADED ❑ -1-c.-MIDGRADE UNLEADE _D ❑ Ib.PREMIUM UNLEADED 440• ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS - ❑ 8 PETROLEUM BLEND FUEL ❑ 9 OTHER PETROLEUM(Specify): 440x. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406. IV TANK CONSTRUCTION TYPE OF TANK _ ❑ 1.SINGLE WALL .DOUBLE WALL ❑ 95.UNKNOWN 443• CO PRIMARY NT_AINMENT _.._.._.,Q 1.STEEL .._...__.. ❑ 3.FIBERGLASS - ❑ 6.INTERNAL BLADDER-- _.... _ .._.___..._ .. _ ..........._...- 444. _ -._-..__- _-...._.__.0,7.STEEL+INTERNAL.LINING -„„ -❑ 95_UNKNOWN ❑ 99.OTHER(Specify): 444a. SECONDARY CONTAINMENT ❑ 1.STEEL (�."b.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE Q 95.UNKNOWN [199.OTHER(Specify): 445a. OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT Q103.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 [ j.PRESSURE ❑ 2.GRAVITY ❑ 3 CONVENTIONAL SUCTION ❑ 4_SAFE SUCTION[23 CCR§2636(ax3)] 458. PRIMARY CONTAINMENT 11 1.STEEL 4.FIBERGLASS [1 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. _ -- ❑ 90.NONE __.❑ 95.UNKNOWN- _.._._❑ 99 OTHER(Specify): 464a. SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. _.__.❑ 90._NONE .._...__ __❑ 95.UNKNOWN Q 99 OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464a. VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS [310.RIGID PLASTIC Q 90.NONE ❑ 99.OTHER(Specify): gbg4e. VENT SECONDARY CONTAINMENT Q 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 46441. ....._.___ _.._ - ..--------..--_-__._ -_ _.._.____._.-_.-_-. .__ _....._.__. VR PRIMARY CONTAINMENT ❑ 1 STEEL 4 FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464g. --_-- _-...__ _..._ ._ 464 I. _.-_ __. 4644. VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ja 90.NONE ❑ 99.OTHER(Specify): 46441. _-- ._. _-._. _-- _.. _-- __.......__. VENT PIPING TRANSITION SUMP TYPE Q 1 SINGLE WALL ❑ 2 DOUBLE WALL 90 NONE 464`. RISER PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): gbg4;: RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC90.NONE [399.OTHER(Specify): 464k. _ 464k1. FILL COMPONENTS INSTALLED 1.SPILL BUCKET STRIKER PLATE/BOTTOM PROTECTOR 13 4.CONTAINMENT SUMP 45la-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2 DOUBLE WALL 0 3 NO DISPENSERS ❑ 90 NONE 469x. .-----------------_,.�___-... ......._. __..... ._._...-- -_..._...._-_.---- ..._....._ .... CONSTRUCTION MATERIAL 1.STEEL [14.FIBERGLASS [310.RIGID PLASTIC [34696. 99.OTHER(Specify) 469c 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 SIGNATURE DATE470. S' 0/ 2 APPLICANT NAME(print) �-s !w *-r, a71. APPLICANT ITLE ,r r�� 472. UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org