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01/13/2009 TUE 16: 12 FAX 209x3433 SJC EHD (Rt&011/013 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. rot a UST closure or removal,complete only this section and Secilons 1,If.///,/V,and IX below) iso ❑ I.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. I DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID N(Agency Use Only) _ _ 1. BUSINESS N ME(Same as l'acil7v Name or DBA--Doing Business As) 3• BUSINESS SITE ADDRESS 103• 1 CITY 104. II. TANK DESCRIPTI16N TANK ID it 432• TANK MANUFACTURER 431• TANK CONFIGURATION:THIS TANK IS 434. ❑ L A STAND-ALONE TANK Complcae one pace for each _-- Qj�YO q03 ❑ 2.ONE IN A COMPARTMENTED UNIT comparuncnt in the unit. DATE UST SYSTEM INSTALLED 435• TANK CAPACITY IN GALLONS tj 436• NUMBER OF COMPARTMENTS IN THE UNIT 437. III. TANK USE AND CONTENTS TANK USE JZ )a.MOTOR VrAilCLC I'UL"•LING ❑ Ib.MARINA FUCI.ING ❑ Ic.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAG13 ❑ 4.HAZARDOUS WASTE(Inclade3 UscA OA) O 5.riME1tGCNCY GENIiItA'I.OR I'-UrJ.IliSC§25281,5(c)) ❑ 6.OT1•ICRGENERATORI:UCL __ ❑ 95.UNKNOWN _ _ [199.OTHL'•R(Specify): 439 UMx• -CONTENTS PETROLEUM: la.RUN EGULAR LEADED - ❑ Ic.MIDGRADE UNLEADED -- _ ,fib.PREMIUM UNLEADED 440. ❑ 3_DIESEL ❑ 5.JGr FUEL 6.AVIATION GAS ❑ 8.PETRO EU M BLEND FUL"•L ❑ 9.OTHER_PuROLGRN (Specify): 140x. NON-PEI'ROLI- ❑ 7.USL-D OIL 0'10.ETHANOL-- --�i - __.. ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION TYPE OFTANK _ ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443, PRIMARY CONTAINMENT 1.STEEL. ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. __ ___ ___ ❑ 7.S•1'ru+INTERN_AL IN _❑_95.UNKNOWN O 99.OTHER(Spccily): 444s. SECONDARY CONTAINMENT A I.STEEL -~- _ f 3.FIBCRGLASS ❑ 6.EXTERIOR MEMBRANE LINER - ❑ 7.1ACKL•"1'.1) ❑ 90.NONE _❑ 95.UNKNOWN _ ❑99.OTHER(_Specify): 445x. OVERFILL PREVENTION p 1.AUDIBLE&VISUAL ALARMS 9 2.BALL FLOAT-- »-» ❑ 3.17111 TUBE SHUT-Off VALVE 452. ❑ 4.TANK MEET'S RE UIRBML•N'rS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑_I.SINGLE WALL 2.DOUBLE WALL ❑ 99.OTHER 460. _SYSTEM TYPE - - - 1.PRESSURE ❑ 2.GRAVITY M�^❑ 3.CONVN'11ONAI,SUC'('ION ❑ 4.SAFE_SUC'r10N 123 MR §3636(x)(3)) 458• PRIMARY CONTAINMENT ❑ I.STCL'L ® 4.FIBERGLASS ❑ 8.fI.EXIBI.,E O 10.RIGID PLASTIC 464. _O 90•NONE ❑ 95.UNKNOWN [199.OTHER(Specify): 464x. SECONDARY CONTAINMENT O-1.S`rEE - 2 4.FIBERGLASS FL VO 8. EXIBLE O 10.RIGID PLASTIC_ ❑ 90.NONC ❑ 9S.UNKNOWN _ ❑ 99.OTHER(Specify): 464c. PIPING/TURBINE CONTAINMENT SUMP TYPE- _� 1.SINGLE WALL ❑ 2.DOUBLE WAW. ❑ 90.NONE: 464d. VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.S'PEL'L 4.FIBERGLASS ❑ 10.RIGID PLASTIC_O 90.NONE ❑ 99.OTHER(Specify): 4444;, _.V ENT SECONDARY CONTAINMENT ❑ (.S'fEGL _ 1 4.FII3CRGLASS ❑ 10.RIGID P[AS'r1C ❑ 90.NONE ❑ 99.OT1ICR(Specify): 4G4 1.y VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ^ ❑ 10.RIGID PLASTIC-T❑ 90.NONE ❑ 99.OTHER(Specify): 4�gQj� A64h. VR SECONDARY CONTAINMENT ❑ I.S'I'EfiL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NUNS ❑ 99.0'1'I•IER(Specify): 46411. VENT PIPING TRANSITION SUMP TYPE JR I.SINGLIS WALL O 2.DOUBLE WALL ❑ 90.NONE. RISER PRIMARY CONTAINMENT JS 1.STEEL. O 4.FIBERGLASS ❑ 10.RIGID Pl.ns'rlC ❑ 90.NONE ❑ 99^O'1_HCR(Specify): 44ai1_ RISER SECONDARY CONTAINMENT ❑ 1.STEEL, ❑ 4.MBE.RGLASS _❑ 10.RIGID ❑ 90.NONE_❑ 99.OT1•IER(Specify): ,TJ,4 46.1-. _ _ ;r _ _ _ 464-1. FILL COMPONENTS INSTALLED 1.SPILL BUCKEir_~- lGt 3.5'I•RIKCIt PLATLJB07.1'OM PROT'L•C'I'OR gJJ 4.CONTA1NMENI'SUMP �Stn:e VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ...I:_SINGL_E WAL(. _ _ D 2;_DOuni.E WALL0 3_NO DISPENSERS �O 90.NON_Is aG9xW CONSTRUCTION MATERIAL ❑ L STEEL M 4.FIBERGLASS O 10.RIGID PLASTIC _-❑ 99.0'I'I.1131t(Specify) 469b, » VIII. CORROSION PROTECTION S'TEELCOMPONENT PROTECTION ❑ 2.SACRIFICIAL.ANODES) O 4.IMPRrSSED CURRfiN'r ❑ 6.ISOLATION 448• IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system is compatible with the hnrardous substance stored and that the information provided herein is true, accurate,and in fuR compliance with 1e nl requirements. APPLICANT SIGNATURF�� - DATE �-15-, O A70' APPLICANT NAME(print) / 471' APPLICANTTITI, A72. UPCF UST-B Rev.(12/201)7)-I/2 www.unidoes.org