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�1 s 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,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: 430a DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 BUSINESS NAME(Same as FAC ITY NAME or DBA-Doing Business As) BUSINESS SITE ADDRESS 103 CITY loa II.TANK DESCRIPTION u{ TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 -92.ONE INA CO FAR TANK UNIT. Complete one page for each compartment in the writ. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 lLIII.TANK USE AND CONTENTS' TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439 " 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(bndudes 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 ❑ ]c.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL J9 9.OTHER PETROLEUM (Specify): 1vr o 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b IV:'TANKCONSTRUCTION TYPE OF TANK 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT JR 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 .OTHER(Specify) .•�cr-.+C, 4 4t5a 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 [12.DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(ax3)] 458 PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS q1 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT rl 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 90.NONE ❑ 95.UNKNOWN 99.OTHER(Specify): c ti 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 464d VI .VENT,VAPOR RECOVERY(VR):AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL El 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464f 464fI VR PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4646 464 I VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT Lj 1.STEEL LI 4.FIBERGLASS Lj 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464j 4601 RISER SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS Ej 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464k 464kI FILL COMPONENTS INSTALLED ❑ I.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 45la-e VII.UNDER DISPENSER CONTAINMENT.(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b� VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑4.IMPRESSED CURRENT M 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST s compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full com lia ith I requirements. APPLICANT SIGNATURE DATE T k<-- 470. APPLICANT NAME(print) 417L APPLICANT T XLE 47 UPCF UST-B-112 Rev.(12/2007)