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IED PROGRAM CONSOLIDATED FOR, f UNDERGROUND STORAGE TANK '�I► '�( ) OPERATING PERMIT APPLICATION-TANK INFORMATION (one form per UST) ti TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11,111,IV,and lxbelow) -43D.. ❑ 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: 430a DATE EXISTING UST DISCOVERED: 430b. L FACILITY INFORMATION' FACILITY ID#(Agency Use Only) _ 1. BUSINESS NAME(Same as Facility Name or DBA-,qoin4 Business As) 3. iiV,4 0 fl-S , BUSINESS SITE ADDRESS 103. CITY 104• II. TANK DESCRIPTION TANK1 # I n 432. TANK MANUFAgURER 433• TANK CONFIGURATION:THIS TANK IS 434• b 1(a 3 132&Slh/(,J► 1.A STAND-ALONE TANK Complete one page for each 2.ONE IN A COMPARTMENTED UNIT compartment in the wit. DATE UST SYSTE14 INSTALLED 435• TANK CAPACITY IN GALLONS 436• NUMBER OF COMPARTMENTS IN THE UNIT 437. (D 16 Ia III. TANKUSE AND CONTENTS TANK USE kF la.MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ lc.AVIATION FUELING 439. 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§2528 LS(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439x. CONTENTS PETROLEUM. ❑ la.REGULAR UNLEADED ❑ la MIDGRADE UNLEADED $Ib.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8 PETROLEUM BLEND FUELY ❑ 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 jf2.DOUBLE WALL [1 95UNKNOWN 4a3. PRIMARY CONTAINMENT ;W 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444• ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444a. SECONDARY CONTAINMENT ❑ 1.STEEL FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. - - --. . ❑ 90.NONE ❑ 95.UNKNOWN ❑_99.OTHER(Sp_ecify): 445x. OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT jjj3.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. OTHER460. SYSTEM TYPE 1 PRESSURE ❑ 4 GRAVITY ❑ 3 CONVENTIONAL SUCTION 4.SAFE SUCTION[23 CCR§2636(ax3)] 458. PRIMARY CONTAINMENT ❑ 1.STEEL JZ4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464• ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify)_: 464a. SECONDARY CONTAINMENT ❑ 1.STEEL FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. _._❑ 90.NONE „ 0,95.UNKNOWN ❑ 99 OTHER(Specify): 464c. PIPING/TURBINE CONTAINMENT SUMP TYPE L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d. VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION' VENT PRIMARY CONTAINMENT ❑ 1.STEEL 4 FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90 NONE-❑ 99 OTHER(Specify): 46441. ---..._ VENT SECONDARY CONTAINMENT ❑ I STEEL ❑ 4 FIBERGLASS [3 10.RIGID PLASTIC 9,90 NONE ❑ 99 4644.OTHER(Specify): 46441. VR PRIMARY CONTAINMENT ❑ 1 STEEL 4 FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90 NONE ❑ 99.OTHER(Specify): 464 g. VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4 FIBERGLASS ❑ 10 RIGID PLASTIC �90 NONE ❑ 99.OTHER(Specify): 464h1. __... .. ........ __._.. --- -_-.. _._. _._ ,. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4 41' RISER PRIMARY CONTAINMENT �1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464.1 RISER SECONDARY CONTAINMENT [I1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 090.NONE ❑ 99.OTHER(Specify): 4641. 4641 1. FILL COMPONENTS INSTALLED jff 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 451a-c. VII. UNDER DISTPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a _ _......_ _.._.......__ _. ..._._-. _ ._..__._ __. _--_. ___ _.__.. _._._._.._ ..-_..__. -._ .......... _..._._._. _...__._ _.__._.. CONSTRUCTION MATERIAL 1.STEEL ❑ 4.FIBERGLASS ❑ 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 SIGNATUR DATE 70. a-o/2 APPLICANT NAME(print) / � i 471' APPLICANT TITLE D 4 Z' 4 UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org