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01/13/2009 TUE 16: 12 FAX 20903433 SJC EHD 0 110011/0a13 1 b� UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK / q OPERATING PERMIT APPLICATION-TANK INFORMATION l (0-fb,'mb�o 1 TYPE OF ACTION (Check one item only. rat-a US7'closure w•removal,complete only this section and Sections 4/1.111,11,and/X 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: 4�0a• I DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID 11(Agency Use Only) _ _ a ,• BUSINESS NAME(Sante as Facii/'[vNate or DBA•-Doing llusiness AS) 3. BUSINESS SITE ADDRESS 103• CITY 104. II. TANK DESCRIPTI16N TANK ID b 432• TANK MANUFACTURER 433• TANK CONFIGURATION:THIS TANK IS 434• ] ❑ L A STAND-ALONE TANK Complete one page for each 011/0 o O 2.10NE IN A COMPARTMENTED UNIT comparuncnt in the unit. DATE UST SYSTEM INSTALLED 435• TANK CAPACITY IN GALLONS V 436. NUMBER OF COMPARTMENTS IN THE UNIT 437• 3- o f- Ici :21 P 000 III. TANK USE AND CONTENTS TANK USE IRr la.MOTOR VI3HICI.13 DUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439• ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Inchtdcs Uscd Oil) ❑ 5.EMERGENCY GENERATOR FUEL IMSC g25281.5(c)) O 6.OTHER GENERATOR DUEL_ ❑ 95.UNKNOWN _ _ `- n 99.OTIirit(S 1(ccify): 439a• -CONTENTS PETROLEUM: ® Ia.REGULAR UNLEADED ❑ 1c.MIDGRADE UNLE'ADE'D ] 16.PREMIUM UNLEADED �] 3.DIESEL ❑ 5.JET FUEL 6.AVIATION GAS ❑ 8.PETROLEUM BLE D FUEL ❑ 9,OTHER PETROLEUM(Specify): 440a. NON-PF.1 ROLTUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.0"I'HER NON-PETROI.EUM(Specify): 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SING1,r WALL 02.DOUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT 1 I.STEEL. ❑ 3.IrIBERGLASS O 6.INTERNAL BLADDER 449• _ _ ❑ 7.STEEL 4-INTERNAL LINING ❑ 95.UNKNOWN O 99.01'HE11(Specily): 444a. ,._____......_._._.__......._.....___._.....__.....____...._......._.._.....__._..___�.._.__._-__._.___....,_._._...._.._ ..._...._ SECONDARY .._.-.........._- CONTAINMENT �J 1.STEEL M3.F10ERGLASS ❑ 6.EXTERIOR MEMBRANE LINER O 7.JACKETED 14S• _ ❑ 90.NONE_ ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445x• OVERFILL PREVENTION - fit] 1.AUDIBLE&VISUAL ALARMS T ® 2.BALL FLOAT---'-T-❑ 3.FILL TUBE SI-IUT•OIT VALVE 452• ❑ 4.TANK MEET'S RE UIR13MENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑_I.SINGLE•WALL_ (a 2.DOUBLE WALL C) 99.OTHER 460. SYSTEM TYPE _ Y-_ _ _ L PRESSURE ❑ 2.GItAVI'fY ---_M�❑ 3�CONVENI'IONAL SUC'!'lON ❑_4.SAFE SUCTION(23.._CCR¢263G(a)(3)1 458. _ _ _ . ~PRIMARY CONTAINMENT ❑ L STEML 0 4.FIBERGLASS, ❑ 8.FI.EXIBI.d•: ❑-10.RIGID PLASTIC 164• ❑ 90.NONE. ❑ 95.UNKNOWN ❑ 99.0'1'IMR(Specify): 464a. SECONDARY CONTAINMENT 0 1.STEEL ® 4.FIBERGLASS O 8.FLEXIBLE ❑ 10.RIGID PLAS'f(C 16,1b. ❑ 90.NONE ❑ 95.UNKNOWN _ ❑ 99.01 HrR(Specify): 464c. PIPING/TURBINE CONTAINMENT SUMP TYPE_ ��I.SINGLE WAIL ❑ 2.DOUBLE WALL O 90.NONE; ----�444a. VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION . VENT PRIMARY CONTAINMENT C] 1 STEEL LL 4.FIBERGLASS C1464e 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464cl: VENT SECONDARY CONTAINMENT ❑ I.S'fEEi_ 4 FI13f:RGLASS�❑ 10.RIGID PLASTIC ❑ 90.NONE' ❑ 99.01'IiER(Specify): 4164' _ VR PRIMARY CONTAINMENT ❑ 1.S'fliL'L 4.1'113GRGLASS ❑ !0.RIGID Q 90.NONE ❑ 99.0'1'lIL•R(Specify):_ _ _ T _ ® 46 bi. VR SECONDARY CONTAINMENT C3 I.STEELY BE ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4611 i. VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE RISER PRIMARY CONTAINMENT 1.STEL:[. ❑ 4.nBERGLASS O 10.RIGID PLAsT(c ❑ 90.NONE ❑ 99.0'f lecif HER S 464y ( 1 yk 4.a4;4_ _RISER SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.nBERGLASS _❑ 10.RIGID PLASTIC (190.NONE ❑ 99.OTlif.•.R_ _ _ (Sp ccif y): �J�q 44;4;; �r _ _ FILL COMPONENTS INSTALLED I.SP1LG BUCKETMw^ 1lt 3.VS'1'R1KEIt PL.ATUBO-I'TOM PROTEC'T'OR - - )® 4.CONTAINMEN'I'SUMP d5in:c:" VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE I.SINGLE WALT. O 2.DOUBLE WALL El 3.NO DISPENSERS^ 0 90.NONE __.._____ 469a• CONSTRUCTION MATERIAL ❑ I.STEEL ,® 4.FI[3EROLASS ❑ 10.111011)PLASTIC [399.OTHER(Specify) 169c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIVICIAL ANODES) ❑ 4.1MPR1iSSED 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 compliance with Ic at requirements. APPLICANT SIGNATUR� DATE -/ d 470. APPLICANT NAME(print) c 471' APPLICANTTITLE 477' UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org