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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 an UST permanent closure or removal,complete only this section and Sections 1,II,III,IV,and IX 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: "OR I DATE EXISTING UST DISCOVERED: 430b L FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 BUSINESS NAME(Same as FA C}I ITY NAME or DBA-Doing Business As) 3 BUSINESS SITE ADDRESS 103 CITY 104 U.TANK DESCRIPTION, 14 51- TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 r^ 1.A STAND-ALONE TANK r Q S X Q 2.ONE IN A COMPARTMENTED UNIT. etc one for each com in the wdt. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 00 M.TANK`USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 J3 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Induda 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 ❑ lc.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS 11 ❑ 8.PETROLEUM BLEND FUEL 9.OTHER PETROLEUM (Specify): r,p`!br 0; 440& 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 J9 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN St99.OTHER(S ): ,•cr-e,-(Lemy 445a OVERFILL PREVENTION 1.AUDIBLE @ VISUAL ALARMS 2.BALL FLOAT h 3.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-WALLED [12.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE L PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(aM3)] 458 PRIMARY CONTAINMENT IN 1.STEEL ❑ 4.FIBERGLASS 11 8.FLEXIBLE ❑ 10.RIGm PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 90.NONE ❑ 95.UNKNOWN 99.OTHER(Specify): orry ti 464c PIPING/TURBINE CONTAINMENT S:,-?TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 9 90.NONE 464d V1.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT L STEEL U 4.FIBERGLASS Ll 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) 4641' 464fl VR PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4646 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 464i. RISER PRIMARY CONTAINMENT Lj L STEEL L1 4.FIBERGLASS U 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464j 4647 RISER SECONDARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATEBOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 45la< VII.UNDER DISPENSER CONTAINMENT"C) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS 90.NONE 469. CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bc 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 co nce ith legal requirements. APPLICANT SIGNATURE DATE 470 /� a7 APPLICANT NAME(print 471. APPLICANT TITLE n °r• UPCF UST-B-1/2 Rev.(12/2007)