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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 I,I1,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: 430a DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 BUSINESS NAME(Same as FACJLITY NAME or DBA-Doing Business As) �, 3 BUSINESS SITE ADDRESS, 103 CITY 104 II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 / 1.A STAND-ALONE TANK -92.ONE IN A COMPARTMENTED UNIT. ComOcte one Pme for each com ent in the ulut. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 S' o M.TANK USE AND CONTENTS' TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439 2 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(htrluda Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(0)] ❑ 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 ❑ 8.PETROLEUM BLEND FUEL J9 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 IW TANKCONSTRUCTION TYPE OF TANK $ L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT JR L STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ L STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN Jjt99.OTHER(S ): _r_r-e,-f e_ m 445a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 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 ❑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 ® L STEEL ❑ 4.FIBERGLASS 11 8.FLEXIBLE []'10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT n 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 90.NONE ❑ 95.UNKNOWN 0 99.OTHER(Specify): () a. �� 464c PIPINGfFURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL V 90.NONE 464d VI .VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464c 464el VENT SECONDARY CONTAINMENT L STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464f 464fl VR PRIMARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4648 464al 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 464L RISER PRIMARY CONTAINMENT L STEEL Lj 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT 0 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 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT(UDC) 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 VIIL; CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT IM 6.ISOLATION 448• IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system' patible with the hazardous substance stored and that the information provided herein is true,accurate, and in full complianctmAt9legaLWguirements. APPLICANT SIGNATURE DATE rp i 470 S IV APPLICANT NAME(print) r ( 471' APPLICANT TITLE n _ 47-'. V W^ UPCF UST-B-1/2 Rev.(12/2007)