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i 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 tion 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: 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) Ql 3 S BUSINESS SITE ADDRESS 3 05e"" ir- ti V a 103 CITY (/1 1 104 II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS - 434 �'T 1��' ❑I.A STAND-ALONE TANK CDM� ONE IN A COMPARTMENTED UNIT. Pift one Pw for each computment in the umt DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF MENTS IN THE UNIT 437 (0 oO U III.TANK USE AND CONTENTS' TANK USE la.MOTOR VEHICLE UELING ❑ lb.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRO CT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENFA ^R FUEL ❑ 95.UNKNOWN ❑ 99.OTHERS OTHER(Specify): 439a CONTENTS PETROLEUM: REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED lb.PREMIUM UNLEADED 440 LI 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-PETROLEUMS i ): 4406 IV.`TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 4q4 ❑ 7.STEEL+INTERN INING ❑95.UNKNOWN ❑ 99.OTHER (specify): 444a SECONDARY CONTAINMENT 0/ STEEL 3.FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑_ 0.NONE )5.UNKNOWN ❑99.OTHER(Specify) 445a OVERFILL PREVENTION .AUDIBLE 8c VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. LJ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRO U T!WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 1.SINGLE-WALLED 412.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ .GRAVITY ❑3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(ax3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL 4.,FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE A5.UNKNOWN ❑99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN -"--,,ER(Specify): 464c PIPING/TURBtNE CONTAINMENT SUMP TYPE 1 SINGLE WALL [ LE WALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECO (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL A,4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL FIBERGLASS ❑ 10.RIGID PLASTIC 2L 90.NONE ❑ 99.OTHER(Specify) 464f 464f1 VR PRIMARY CONTAINMENT ❑ 1.STEEL W4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL FIBERGLASS ❑ 10.RIGID PLASTIC jk9O.NONE ❑ 99.OTHER(Specify) 464h VENT PIPING TRANSITION SUMPTYPE 1.SINGLE W L ❑2.DOUBLE WALL 90.NONE 464h CONTAINMENT t RISER PRIMARY 1.STEEL FIBERGLASS ❑ l0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT ❑ '.STEEL X 4.FIBERGLASS 0 10.RIGID PLASTIC NONE 0 99.OTHER(Specify) 464k 4641 FILL COMPONENTS INSTALLEDISV 1.SPILL BUCKET 0 3.STRIKER PLATEBOTTOM PROTECTOR 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSEP`---iTAINMENT.(UDC) CONSTRUCTION TYPE XI.SINGLE WALL L _._-UBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL : 1.STEEL R4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 99.OTHER(S fy) 469bro VIIL CORROSIONTROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑4.IMPRESSED CURRENT 6.ISOLATION 448• IX. APPLICANT SIGNATURE CERTIFICATION: I certi ST system is com with the ous substance stored 70 that the information provided herein is true,accurate, and Wfull compliance with leizal APPLICANT SIGNATU DATEmow) �/ 470. (/ . APPLICANT NAME(print) 471' APPLICANT T E / 47z. UPCF UST-B-1/2 Rev.(12/2007)