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UNIFIED PROGRAM CONSOLIDATED FORM (C) UNDERGROUND STORAGE TANK le- �I 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 ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4301 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 BUSINESS NAME(Same as FACITY NAME or DBA-Doing Business As) BUSINESS SITE ADDRESS 103 CITY 104 e- II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS434 d Sl Sg 3 -92.ONE IN A COMPARTALONE MENTED UNIT. Complete one page for each cornpartmerit in the umt DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 /t:0 M.TANK USE AND CONTENTS TANK USE Tl Ia.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ ►c.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE 4.HAZARDOUS WASTE(Ind�des Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL IHSC§25281.5(c)] V 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 43% CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.]ET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ).OTHER PETROLEUM (Specify): 440a NON-PETROLEUM: 7.USED OIL - 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b IV.'TANKCONSTRUCTION TYPE OF TANK 1.SINGLE WALL 512.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT X I.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT Q 1.STEEL ❑3.FIBERGLASS r 16.EXTERIOR MEMB "^'^'t ^ ' ' ^' ^^ 445 ❑ 90.NONE ❑ 95.UNKNOWN !99.OTHER(Specify): 4451 OVERFILL PREVENTION 1.AUDIBLE$VISUAL ALARMS 0 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(.x3)] 458 PRIMARY CONTAINMENT R L STEEL ❑4.FIBERGLASS ji 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL ❑4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 90.NONE ❑ 95.UNKNOWN *99.OTHER(Specify): - 464c PIPINGITURBINE CONTAINMENT-'—.P TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 11 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT LJ L STEEL Ll 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464f 4648 VR PRIMARY CONTAINMENT EJ 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464g 4640 VR SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE In 1.SINGLE WALL Q 2.DOUBLE WALL 90.NONE 464L RISER PRIMARY CONTAINMENT Ll L STEEL 4.FIBERGLASS 10.RIGID PLASTIC j 90.NONE 0 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 0 1.SPILL BUCKET 3.STRIKER PLATEBOTTOM PROTECTOR 4.CONTAINMENT SUMP 451a-c VII.UNDER DISPENSER CONTAINMENT.(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS 90.NONE 469a CONSTRUCTION MATERIAL ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b•c VIII.;'CORROSION;PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑4.IMPRESSED CURRENT JM 6.ISOLATION 448. DL APPLICANTSIGNATURE CERTIFICATION: I certify that this UST m is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full compiladee widi legal requirements. APPLICANT SIGNATURE C DATE 470. APPLICANT NAME(print) t , 471' APPLICANT TITLE ca �lp�cv� +fes UPCF UST-B-1/2 Rev.(12/2007)