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UNIFIED PROGRAM CONSOLEDATED FORM UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) E OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 430 1.NEW PERMIT [13.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: 430) FACILITY ID#(Agency Use Only) BUS SS N (SameasFACILITY NAME or DBA-Doing Business As) t 3 r® BUSINESS SIT RE Q ®l-nc 103 CITY 104 1re ITT , DESCRIPE)N TANK ID# �/^ 432 TANK MANUFACTURER 433 T CONFIGURATION:THIS TANK IS 434 ' [1'�V.A STAND-ALONE TANK L.ONE IN A COMPARTMENTED UNIT. Complete one pap for each convartmerd in the writ DATE UST SYS I F INSTALLED 433 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 'L$.`1 TANK USE la.MOTOR VEHICLE FUELING ❑ ib.MARINA FUELING ❑ lc.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Indndes 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 [3 la MIDGRADE UNLEADED [I Ib.PREMIUM UNLEADED 440 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (S 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 44Ub, IV.:TANK-CONSTRUeTION . TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ I.STEEL KP 3.FIBERGLASS ❑6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNALLINING ❑95.UNKNOWN ❑ 99.OTHER (S 444a SECONDARY CONTAINMENT ❑ 1.STEEL 3.FBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE 95.UNKNOWN ❑99.OTHER(S ): 445a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT IA 3.FILL TUBE SHUT-OFF VALVE 452. ❑4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL-PREVENTION EQUIPMENT t?.PR®pUCT l WASTE PIPING C®NSTRiTGT°I®N. PIPING CONSTRUCTION ❑1.SINGLE-WALLED 5a 2.DOUBLE-WALLED ❑99:OTHER 460 SYSTEM TYPE 1.PRESSURE ❑2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(ax3)] 458 PRIMARY CONTAINMENT 0 1.STEEL ❑4.FIBERGLASS ❑8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE 665.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL QI 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑2.DOUBLE WALL ❑ 90.NONE 464d .VI.VENT,VAPOR:RECOVERY(�R)AND 7 FILI.>PIPE PIPIlYGr�ONSTRUGTION VENT PRIMARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS El 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑90.NONE ❑ 99.OTHER(Specify) 464f 464tI VR PRIMARY CONTAINMENT L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑90.NONE 0 99.OTHER(Specify) 464g 464 I VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE Q 1.SINGLE WALL 0 2.DOUBLE WALL 90.NONE 464L RISER PRIMARY CONTAINMENT Q L STEEL ❑ 4.FIBERGLASS U 10.RIGID PLASTIC ❑90.NONE 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC ❑90.NONE El 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATEBOTTOM PROTECTOR 4.CONTAINMENT SUMP 451a-c VII,UNbER"DISPENSED CONT' NT.MIC CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION IA MATERL ❑ L STEEL. 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑99.OTHER(Specify) 469bc VIII CO OSI®N PR CTION" STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. .; IX. A$PLICANT SIGMA ,. CERTIFICATION:I certify that this ,ST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full com ce with legal requirements. APPLICANT SIGNATURE470. 0 DATE � 115 d� APP ICANT NAME rint) 471' APPLIC TITL an. UPCF UST-B-1/2 Rev.(12/2007)