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UNIFIED PROGRAM CONSOLIDATED FORM ��pp <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATIO (one o r UST) <br /> TYPE OF ACTION (Check one item only. For a UST closure or removal.complete only this section and Sections 1.11.111.IV,and IX bel ) 430. <br /> J 1.NEW PERMIT El3.RENEWAL PERMIT ❑ 5.CHANGE OF INFO AT(ON <br /> 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430- 1 DATE EXISTING UST DISCOVERED: L7 pC 1. 2p1 410b. <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) - - l I I 2 1. <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3' <br /> fufLMr,L- LW03 Pelf_t" <br /> BUSINESS SITE ADDRESS 103• CITY 104' <br /> 2$Z9 W �„/J}tlfiN�troM ST Sntt�T�rJ <br /> II". TANK DESCRIPTION <br /> TANK ID# TANK MANUFACTURER 433• TANK CONFIGURATION:THIS TANK IS 434. <br /> EF 1.A STAND-ALONE TANK Complete we page for each <br /> V AIP WSJ 2.ONE IN A COMPARTMENTED UNIT compartment in the wit. <br /> DATE UST SYSTEM INSTALLED 435• TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. <br /> N 4V z <br /> III. TANK USE AND CONTENTS <br /> TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING [3 1c.AVIATION FUELING 439. <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Include,used Oil) ❑ 5.EMERGENCY GENERATOR FUEL(HSC§25281.5(c)] <br /> ENERATOR FUEL AK95.UNKNOWN ❑ 99.OTHER(Specify): 439e. <br /> CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED Lj lb.PREMIUM <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL a 9.OTHER PETROLEUM(Specify): 60101110- %VA-tTA-+TAA La <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> 11.OTHER NON-PETROLEUMS i 'rfti4. C V PJt!•�lR. 440b. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK 2.DOUBLE WALL 95.UNKNOWN _443'__ <br /> PRIMARY CONTAINMENT ❑ 1.STEEL [33.FIBERGLASS [36.INTERNAL BLADDER 444. <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN bk 99.OTHER(Speci GrN C Z,9-W- 444i <br /> SECONDARY CONTAINMENT ❑ L STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445• <br /> 90.NONE [395.UNKNOWN [199.OTHER(Specify): <br /> 445a <br /> OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452• <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION 1.SINGLE WALL ❑ 2.DOUBLE WALL E3 99,OTHER 460. <br /> SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION L23 CCR§2636(,)(3)] 458. <br /> PRIMARY CONTAINMENT L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. <br /> 90.NONE (395.UNKNOWN [399.OTHER(Specify): 464a <br /> SECONDARY CONTAINMENT [31.STEEL [34.FIBERGLASS [38.FLEXIBLE [3 10.RIGID PLASTIC 4646. <br /> 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE [31.SINGLE WALL ❑ 2.DOUBLE WALL 0.NONE a6aa. <br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT SrL STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑99.OTHER(Specify): 464et <br /> VENT SECONDARY CONTAINMENT [31.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE (399.OTHER(Specify): 464t1 <br /> WF- <br /> VR PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS (:110.RIGID PLASTIC ❑ 90.NONE El99.OTHER(Specify): 4640. <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS [310.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 4 1. <br /> 46x4 <br /> VENT PIPING TRANSITION SUMP TYPE [31.SINGLE WALL [32.DOUBLE WALL 90.NONE <br /> RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC [390.NONE ❑ 99.OTHER(Specify): 4640j: <br /> 464 <br /> RISER SECONDARY CONTAINMENT [31.STEEL [34.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 464kl. <br /> FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET 19 3.STRIKER PLATEIBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45a-c. <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE L SINGLE WALL ❑ 2.DOUBLE WALL 3.NO DISPENSERS ❑90.NONE 469a <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL [34.FIBERGLASS [310.RIGID PLASTIC %99.OTHER(Specify) r w(_(Lwi'F 469b. <br /> 4(flc. <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the Information provided herein is true, <br /> accurate anB compliance with legal requirements. <br /> L 470. <br /> DATE <br /> APPLICANT SIGNATURE � ';� ULT Z O l� � <br /> APPLICANT NAME(print) 471'61, APPLICANT TITLE LetiW" ,� a4r.. <br /> C t, <br /> UPCF UST-B Rev.(12/2007)-1/2 l www.unidoes.org <br />