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�i►' t,( � E7/" . FIED PROGRAM CONSOLIDATED FO WI S /t C✓y+L 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 section 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: "0a DATE EXISTING UST DISCOVERED: 430b I. FACILITY INF'ORNIATION FACILITY ID#(Agency Use Only) 1 - 1 _7 7 3 1 BUSINESS NAME(Same as FACILITY N�E or DBA-Doing B m* :^g EE ' 3 1M � t l uta BUSINESS SI APDk 113 CTTy 104 LCd II.TANK DESCRIPTION TANK ID# rr� h'L j [� j 432 TANK MANUFACTUREER 433 TANK CONFIGURATION: THIS TANK IS 434 \\ V 77 Cse- �� ❑1.A STAND-ALONE TANK J `,•1'�� ,e ms (� ��,,/� F-12.ONE INA COMPARTMENTED UNIT. L Complete one page for each compartment in the unit. DATE UST SYST T LLED 435 TANK CAPAC IN GALLONS 436 NUMBER OF CQMPARTMENTS IN THE UNIT 437 tif TANK USE AND CONTENTS_' TANK USE &7-4a' MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ Ic.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: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 JK3.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(Specify): 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL W2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT STEEL 0 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN Cl 99.OTHER (Specify): 444a SECONDARY CONTAINMENT 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER �}<JACKETED e4/ d o 445 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify)' OV11C S'TJ'L( 445a OVERFILL PREVENTION 1.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-WALLED U2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE .�J.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(ax3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL CR-A FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL � FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE I_[ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGITURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPORRECOVERY(VR)AND.RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT 1.STEEL4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464f 464fl VR PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464g 464g 1 VR SECONDARY CONTAINMENT 0 L STEEL FIBERGLASS 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE L SINGLE WALL .DOUBLE WALL 0 90.NONE 4641. RISER PRIMARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT 0 1.STEEL FIBERGLASS 11 10.RIGID PLASTIC 0 90.NONE C1 99.OTHER(Specify) 464k FILL COMPONENTS INSTALLED464k1 ❑ I.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR CONTAINMENT SUMP 45la-c VIL.UNDERDISPENSERCONIAINMENT(UDC) CONSTRUCTION TYPE ❑ I.SINGLE WALL -G"-DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 99.OTHER(Specify) 469b-c VIII: CORROSIONPROTECTION - STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION IX. APPLICANT SIGNATURE` CERTIFICATION: I certify that this ST syste is rnm a'ble with the hazardous substance stored and that the information provided herein is true,accurate, and in full co nce 't re u' ments. APPLICANT SIGNATURE DATE 470• APPLICANT NAME(p' t 471' APPLICANT TITL 472• UPCF UST-B-1/2 Rev.(12/2007)