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ASL (7- ;- Ll M UNIFIED PROGRAM CONSOLIDATED FORM t,t f - UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (One form per UST) N (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 IT ❑ 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION RY UST CLOSURE 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL FID ANENTLY CLOSED: 4304DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION Agency Use Only) 1 BUSINESS NAME (Same as FACILITY NAME or DBA-Doing Business As) 3 rt Rs - - Ytf OIL C� 9 to3 BUSINESS SITE ADDRESS ff UAV" W 1' 1511/i CITYta4 % �i i� IL TANK DESCRIPTION - TANK ID # 77-A cc%' S 1 32 cy TANK MANUFACTURER 433 V S co TANK CONFIGURATION. THIS TANK IS 434 ❑ 1. A STAND-ALONE TANK 5t2. ONE IN A COMPARTMENTED UNIT. Coh*dc one papfor each computinent in the wit. - DATE UST SYSTE)INSTALLLED 435 ®NS 436 TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS IN THE UNIT 437 III: TANK USE AND CONTENTS' TANK USE j8( la. MOTOR VEHICLE FUELING ❑ Ib. MARINA FUELING ❑ lc. AVIATION FUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 5. EMERGENCY GENERATOR FUEL [HSC §25281.5(c)] ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ i a. REGULAR UNLEADED ❑ 1 c. MIDGRADE UNLEADED ❑ 11). PREMIUM UNLEADED 440 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ S. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM Sec' 440a NON-PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ❑ 11. OTHER NON-PETROLEUM(Specify): 4406 IV. 'TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL 2. DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT M 1. STEEL El 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 [199. OTHER (S ): 445a OVERFILL PREVENTION 1. AUDIBLE & VISUAL ALARMS ff 2. BALL FLOAT of 3. FILL TUBE SHUT-OFF VALVE 452. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT 4 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(ax3)] 458 PRIMARY CONTAINMENT ❑ 1. STEEL 4. FIBERGLASS ❑ 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 464b ❑ 90. NONE 95. UNKNOWN ❑ 99. OTHER (Specify): 464, PIPING/TURBINE CONTAINMENT SUMP TYPE 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE 464d VI. VENT; VAPOR; RECOVERY (VR) AND RISER /FILL PIPE :PIPINGCONSTRUCTION ' VENT PRIMARY CONTAINMENT El 1. STEEL WL 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ff 99.OTHER (Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ I0. RIGID PLASTIC JR 90. NONE ❑ 99. OTHER (Specify) 464f 464fl VR PRIMARY CONTAINMENT 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464g 464 I VR SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC 19 90. NONE ❑ 99. OTHER (Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE0 I. SINGLE WALL ❑ 2. DOUBLE WALL JR 90. NONE 4641. RISER PRIMARY CONTAINMENT 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE 99. OTHER (Specify) 464j 464'1 RISER SECONDARY CONTAINMENT 1. STEEL El 4. FIBERGLASS 0 10. RIGID PLASTIC JQ 90. NONE 99. OTHER (Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1. SPILL BUCKET OU STRIKER PLATE/BOTTOM PROTECTOR 0 4. CONTAINMENT SUMP 45141 VII. UNDER DISPENSERCONTAINMENT fUDC) 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 c VIII.- CORROSIONYROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT 6. ISOLATION 448. IX. 'APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate, and in full mompliance with leeal re uirements. APPLICANT SIGNATU DATE azo. �-I Lf-0 9 APPLICANT NAME (print) AMP �- 471' 1'i Pht- 1 1 Wm l,t�, 4 APPLICANT TITLE 72. r^ G o �. UPCF UST -B - 1/2 Rev. (12/2007)