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UNIFIED PROGRAM CONSOLIDATED FORM' n n UNDERGROUND STORAGE TANK /vv OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete [1 1.NEW PERMIT mp only this section and Sections I,II,III,N,and IX below) "0❑ 3•RENEWAL-PERMIT 0-5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 0 7.UST PERMANENT CLOSURE ON SITE Q 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: DATE EXISTING UST DISCOVERED: 430b L 'FACYL'!'3tIli�I�ORMA1'Ol . FACILITY ID#(Agency Use Only) BUSINESS NA11 (Same as FACILITY NAME or DBA-Doing Business As) 3 �1(��✓*�i5� BU� E ADDRES _ 103 CITY Wim l L� cl 104 TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK 1S 434 ANK 02.ONE INAALONE�TmENrEDUNIT. Complete one Pine for ewh cmnairunew in the mrit. DATE UST SYS""IiS31ALLED 435 TANK CAP ."ALLONS 436 NUMBER O COMPARTMENTS IN THE UNIT 431 SII:TANK73E AND. ONl'ENT$ . TANK USE [3--la.MOTOR VEHICLE FUELING ❑ ib.MARINA FUELING ❑ lc AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(tadudea Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL(HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑99.OTHER(Specify): 43, CONTENTS PETROLEUM: la REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 3.DIESEL ❑ 5.JET FUEL ❑6.AVIATION GAS ❑S.PETROLEUM BLEND FUEL ❑9.OTHER PETROLEUM (Speeft 440a NON-PETROLEUM:❑7.USED OIL ❑ 10.ETHANOL ❑ I I.OTHER NON-PETROLEUM : 440b TYPE OF TANK 1.SINGLE WALL 2.DOUBLE WALL Q 95.UNKNOWN 443 PRIMARY CONTAINMENT 13 1.STEEL I 1&3.FIBERGLASS E3 6.INTERNAL BLADDER 444 7.STEEL+INTERNAL L94ING ❑95.UNKNOWN ❑ 99.OTHER (S 444a SECONDARY CONTAINMENT 1.STEEL .FIBERGLASS 156.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑90.NONE 95.UNKNOWN 13 '99.OTHER(S ): 445z OVERFILL PREVENTION I.AUDIBLE&VISUAL ALARMS .BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 4.11 ❑4.TANK MEETS REQUIREMENTS FOR EXBOTION FROM OVERFILL PRyE�lVEN77ON EQUIPMENT PIPING CONSTRUCTION ❑1.SINGLE-WALLED 2 DOUBLE WALLED ❑99.OTHER 460 SYSTEM TYPE Q 1.PRESSURE E3 2.GRAVITY ❑3.CONVENTIONAL SUCTION 4.SAFE SUCTION CCR§2636(ax3) 458 PRIMARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS ❑8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑95.UNKNOWN ❑99.OTHER(Specify): q6y SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464b ❑90.NONE 0 95.UNKNOWN ❑99.OTHER(Specify): 464c PRINGEURBINE CONTAINMENT SUMP TYPE 19 1.SINGLE WALL ❑2.DOUBLE WALL ❑ 90.NONE 464d w . . :"V.I4 V�I`I;V'APOR,;RECOYERY`�j A�1)RISER/Fifj'L'PII'E, - - 1�nvG t1# trCTIO VENT PRIMARY CONTAINMENT u 1.STEEL 10 4.FIBERGLASSU 10.RIGID PLASTIC 17190.NONE �99.OTHER(Specify) 464e VENT SECONDARY CONTAINMENT I.STEEL 13 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464f VR PRIMARY CONTAINMENT I.STEEL El 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 44664, VR SECONDARY CONTAINMENT El 1.STEEL ❑ 4.FIBERGLASS 13 10.RIGID PLASTIC 16 90.NONE 13 99.OTHER(Specify) 464h VENT PIPING TRANSITION SUMP TYPE I.SINGLE WALL Q 2.DOUBLE WALL 90.NON: 46441 4641. RISER PRIMARY CONTAINMENT 1.STEEL ja 4.FIBERGLASS LI 10.RIGIDPLASTIC 90.NONE 099.OTHER(Specify) 464j RISER SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS LI 10.RIGIDPLASTIC90.NONE 099.5THER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR NT 4.CONTAINMBSUMP 451a.c .vi1L ' ISP CQLN ' CONSTRUCTION TYPE 1.SINGLE WALL ❑2.DOUBLE WALL ❑3.NO DISPENSERS 1390.NONE 469a CONSTRUCTION MATERIAL STEEL 4.FIBERGLASS 10.RIGID PLASTIC 99.OTHER($ 9) 46hc , VIII OOOIQ1�t EL COMPONENT PROTECTION IO�!l STE ❑ 2.SACRIFICIAL ANODES) ❑4.IMPRESSED CURRENT ❑ 6.ISOLATION -44L IX. APPLIGANSI( TATORF CERTIFICATION:I certify that fhb UST system is compatible with the hazardous substaacs stored and that the information provided herein is true,accurate, and In fall compliance with legal requirements. APPLICANT SIGNATURE DATE (, (04-1 G� Oro. 471. APPLICANT TITLE 4?L UPCF UST-B-1/2 'x Rev.(12/2"'