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FIED PROGRAM CONSOLIDATED FO UNDERGROUND STORAGE TANK Z k- S OPERATING PERMIT APPLICATION -TANK INFORMATION (0ne f41 \O TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11,111,IV,and IV below) 430. �\ ❑ 1.NEW PERMIT 'El 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430& I DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ - 1 B INESS NAME(Same as Facility Name or DBA-Doing Business As)_ 3 BU SS SI E ADDRESS 103 CITY loa. II. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTU R 433. TANK CONFIGURATION:THIS TANK IS 434• 1 O �� ❑ 1.A STAND-ALONE TANK Complete one page for each 2.ONE INA COMPARTMENTED UNIT compartment in the unit. DATE UST S STEM INS17ALLED 435. TANK CACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. III. TANK USE AND CONTENTS TANK USE -9 la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ 1c.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)l ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439& CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440• �8 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(S i ): 4406. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL® 2.DOUBLE WALL ❑ 95.UNKNOWN _ 443 PRIMARY CONTAINMENT 1Q 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. _ ❑ 7.STEEL+INTERNAL LINING _❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444a.- SECONDARY 44&SECONDARY CONTAINMENT ❑ 1.STEEL --M 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445& OVERFILL PREVENTION ----® I.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 WALL 2.DOUBLE WALL ❑ 99.OTHER 460. SYSTEM TYPE _ �� 1.PRESSUR_E _ ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)1 458. PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. _ ❑ 90.NONE_ ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464& SECONDARY CONTAINMENT ❑ 1.STEEL ---® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. _ ❑ 90.NONE ❑ 95.UNKNOWN _ ❑ 99.OTHER(Specify): 464a PIPING/TURBINE CONTAINMENT SUMP TYPE --4N 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE a6ad. VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I.STEEL �4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 1399.OTHER(Specify): 46 . VENT SECONDARY CONTAINMENT ❑ 1.STEEL -El .FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [199.OTHER(Specify): 4644Flt 4 . VR PRIMARY CONTAINMENT ❑ 1.STEEL- 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 43 ---- ------------------- ---- VR SECONDARY CONTAINMENT [11.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC-J 90.NONE [399.OTHER(Specify): 464h1. VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4 '' `�L-.................._.__......._--- - - M464i RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [199.OTHER(Specify): 464jil. RISER SECONDARY CONTAINMENT [31.STEEL---N 4.FIBERGLASS ❑ 10.RIGID PLASTIC [390.NONE [199.OTHER(Specify): 46�4kj FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATEIBOTTOM 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 [14.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this US stem is compatible with the hazardous substance stored and that the information provided herein is true, accurate,and iuJiff-coeOance with legal requirementL APPLICANT SIGNATURE DATE -ZS G <, 470. APPLICANT NAME(print I 471. APPLICANT TITLE ' ' ::r 472. UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org 2VF,