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WFIED PROGRAM CONSOLIDATED F UNDERGROUNDSTORAGET ANK OPE G PE PLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only thisc'on and Sections 1,11,111,IV,and IX below) 430 [] 1.NEW PERMIT 0 3.RENEWAL PERMIT CHANGE OF INFORMATION 'I 0 6.TEMPORARY LIST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE *8'UST REMOVAL 430b DATE UST PERMANENTLY CLOSED: 430a I DATE EXISTING UST DISCOVERED: FACILITY ID#(Agency Use Only) I. FACILITY INFOTION RMA _ I 1 1 BUSMSS NAME(Spyg ILI Y NAME or Dg- Ing Business As) r 3 BU�Rjq!y AD SS 103 CITY 104 11.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 El 1.A STAND-ALONE TANK lyl� Al 0 2.ONE IN A COMPARTMENTED UNIT- Com .2late onepage for each compartment in the unit. 437 DATE UST SYSTEM INSTALLED 435 TANK CAP 436 NUMBER OF COMPARTMENTS IN THE UNIT III.TANK USE AND CONTENTS TANK USE 0 Ia.MOTOR VEHICLE FUELING [I lb.MARINA FUELING [3 Ic.AVIATION FUELING 439 �Ij ,CHEMICAL PRODUCT STORAGE 0 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL fHSC 425281.5(c)] 439a W6.OTHER GENERATOR FUEL [3 95.UNKNOWN ❑ 99.OTHER (Specify): 440 [3 CONTENTS PETROLEUM: 11 a.REGULAR UNLEADED 0 Ic.MIDGRADE UNLEADED 0 lb.PREMIUM UNLEADED .DIESEL 5.JET FUEL [36.AVIATION GAS 440a fs.PETROLEUM BLEND FUEL [3 9.OTHER PETROLEUM (Specify): NON-PETROLEUM: 7.USED OIL U 10.ETHANOL 440b 11.OTHER NON-PETROLEUM(Specify): IV. TANK CONSTRUCTION 443 TYPE OF TANK (j1.SINGLE WALL 2.DOUBLE WALL U 95.UNKNOWN 444 PRIMARY CONTAINMENT 0 1.STEEL 3.FIBERGLASS ❑-6.INTERNAL BLADDER 444a 0 7.STEEL+INTE AL LINING 0 95.UNKNOWN 0 99.OTHER (�Mify): 445 SECONDARY CONTAINMENT 0 1.STEEL 'M 3.FIBERGLASS [3 6.EXTERIOR MEMBRANE 0 7.JACKETED 445a Ej 90 NONE r195.UNKNOWN 0 0 99.OTHER(Specify); , - 452. OVERFILL PREVENTION I.AUDIBLE&VISUAL ALARMS 14r_2.BALL FLOAT EAU.FILL TUBE SHUT-OFF VALVE ❑ 4.TANK WETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION-- 0 1.SINGLE-WALLED M2.DOUBLE-WALLED HER 4610 0 SYSTEM TYPE [3 1.PR SSURFM�-GRA�TrY CONVENTIONAL SUCTION 0 4.SAFE SUCTION[23 CCR§2636(aN 468 464 PRIMARY CONTAINMENT [31.STEEL X$4.FIBERGLASS C] 8.FLEXIBLE 0 10.RIGID PLASTIC 464a 0 90.NONE C395.UNKNOWN 0 99.OTHERS, _ _ pecify): , SECONDARY CONTAINMENT [] 1.STEEL 4.FIBERGLASS [3 8.FLEXIBLE [3 10.RIGID PLASTIC 464b 13 90.NONE 0 95.UNKNOWN (3 99.OTHER(SpEify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE [3 1.SINGLE WALL 0 2.DOUBLE WALL [3 90.NONE 464d VI.VENT,VAPOR RECO (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT U 1.STEEL Mg.4.FIBERGLASS U 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 464* 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 464f 464fl VR PRIMARY CONTAINMENT 0 1.STEEL 0-4.-FIBERGLASS [3 10.RIGID PLASTIC 0 90.NONE E3 99 OTHER(Specify) 4646 464 VR SECONDARY CONTAINMENT 0 1.STEEL [1 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE El,1.SINGLE WALL 2.DOUBLE WALL 0 90*NONE 464i. RISER PRIMARY CONTAINMENT t.STEEL 4.FIBERGLASS U 10.RIGID PLASTIC E] 90.NONE U 99.OTHER(Specify) 464j 464il RISER SECONDARY CONTAINMENT [3 1.STEEL U 4.FIBERGLASS 10.RIGID PLASTIC 0 90.NONE [1 99,OTHER (specify) 464k 464kl FELL COMPONENTS INSTALLED -0-1.WILL BUCKET [3 3.STRIKER PLATE/BOTTOM PROTECTOR [3 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL [1 2.DOUBLE WALL [1 3.NO DISPENSERS [3 90.NONE 469a CONSTRUCTION MATERIAL 0 1.STEEL [3 4.FIBERGLASS 0 10.RIGID PLASTIC U 99.OTHER(Specify) 469b-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION [3 2.SACRIFICIAL ANODE(S) 0 4.IMPRESSED CURRENT 0 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 requiLements. 470. APPLICANT SIGNATU�RE5� DAI�� APPLICANT NAME(print) 471. APPLICANT TITLE 472. UPCF UST-8-1/2 Rev.(12/2007)