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01/13/2009 TUE 16: 12 FAX 209nc 3433 SJC EHD 0011/013 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) ITYPECIFACTION (Check one item only. For a UST'closure or removal,complete only this section and Sections/,/l,/II,IV,and IX below) 430. ❑ I.NEW PERMIT ® 3.RENEWAL PERMIT ❑ S.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: 1306. I. FACILITY INFORMATION FACILITY IDN(Agency Use U»!v) - � 1 BUS IN ESS N M E(Same as Facl/Yv Narne or D84-Doing Business As) 3. BUSINESS SITE ADDRESS X03• CITY 104. II. TANK DESCRIPTI N TANK ID N 432• TANK MANUFACTURER 433• TANK CONFIGURATION:THIS TANK IS 434. , ❑ L A STAND-ALONE TANK Complete one page for tach Q �e !tU D 2.ONE IN A COMPARTMENTED UNIT comparimcnl in the unit. DATE UST SYSTEM INSTALLED 435• TANK CAPACITY IN GALLONS LJ 436• NUMBER OF COMPARTMENTS IN THE UNIT 437. 3- off- III. TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUrLING ❑ Ic,AVIATION FUELING 439• ❑ 3.CHEMICAL.PRODUCT'STORAGE' ❑ 4.HAZARDOUS WASTEpnchnIcs Used OO) ❑ 5.EMERGENCY GENERATOR FUL•L(rISC§25281.5(c)) ---J ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTtIEIi(S nl ccify)` 439.• _ ..-..__......_.___,_.___.__...1....1.....1...1...._..__ ......_...... CONTENTS PETROLEUM: ❑ )a.REGULAR UNLEADED ❑ Ic.MIDGRADr UNLEADED .0 1b.PREMIUM UNLEADED 440• ❑ 3-DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PL"TROLEUM BLEND FUL"•L ❑ 9.OTHER PETROLEUM(Specify): 4403. _ 111.1_..___.._._..._ .--------•_----- 11...11_ _.. NON-PF.1 ROLFUM:❑ 7.USED 011. ❑ 10.ETHANOL ❑ 11.O`]TIER NON-PETROLEUM(S petit): 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGL E WALL ® 2.DOUBLE WALL, ❑ 95.UNKNOWN 147• _...__�..-. _.._._.._.....__....__.._...........,._..._._.....__..._._._..._._...._..._._.____.......-._____..__._..._.....___......_...._.____.._._..-._____._..___,..,._....._......1111.. PRIMARY CONTAINMENT 1� 1.STEEL. ❑ 3.FIBERGLASS D 6.INTERNAL BLADDER 1144• _ ___ _ ❑ 7.S•1'L'•EL 4 INTERNAL LINING_ C395.UNKNOWN ❑ 99.011IER(Spcci(y): 444x. - - -.,......11..1.1_......._... SECONDARY CONTAINMENT J291.STEEL M3.FIBERGLASS ❑ 6.EXTERIOR MrMBRANE LINER _ ❑ 7.JACKETED 145• ❑ 90.NONE: ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a. .__....__._..____.._...._._.............._.___....._._..._._..._._._.u._..__.._.._._.___._.._.___._.-.____........._.__........_.._.___.._.,_..111.....1._ OVERFILL PREVENTION fM 1.AUDIBLE&VISUAL ALARMS ® 2.BALI,FLOAT ❑ 3.BILL TUBE SHUT-OFF VALVE 452• ❑ 4.TANK MELTS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/ WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑_I.SINGLE•WALL X 2.DOUBLE WALL ❑ 99.011IER 460. -SYSTEM TYPE ---W--v-J 1.PRESSURE: - ❑ 2.GRAVITY -m -M�❑ 3.CONVE TIONAL SUCI'ION uu❑ 4.SAFE SUCTION(23 CCR¢2636(3)(3)) 458. .._._._.�_ _ - 4�^ 1...1..11_ _ _ _ _. .__-._...-_ ..... .-._...___... PRIMARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS El 8.rLExIBL.E ❑ 10.RIGID PLASTIC 464. D 90.NONE ❑ 95.UNKNOWN ❑ 99.0'11iE•R(Specify): 464x. SECONDARY CONTAINMENT ❑ I.S'1'L'L:L 4.FIBERGLASS O 8.FLEXIBLE ❑ 10.RIGID PLASTIC: 4636. ❑ 90.NONE. ❑ 95.UNKNOWN ❑ 99.01''11ER(Specify): 464c. ------------------------ _-------.1111. -_-_ PIPING/TURBINE CONTAINMENT SUMP TYPE I$ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NOM: 464d. VI. VENT, VAPOR RECOVERY (VR) AND RISER/ FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.sn'(LL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464c' _ _ _ ❑ __ _ I P Y) 464c1. VENT SECONDARY CONTAINMENT ❑ 1.STEEL. 0 4.1`113ERGLASS-❑Y 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.01111111(Specify): 4G4 f1 .__....._.....____._..._.__._..-..__...-_____.____._.___._..____----.__._-_�.-----._......_._-._..__.-.._____.__._._.._______.___.___....-.............1....1,.1............1.._._ .,_......._.. VR PRIMARY CONTAINMENT ❑ I.S•fEEL 4.FIBERGLASS 10.RIGID PLASTIC_ ❑ 90.NONE 99.0TIIL•R(Specify): 4646' _ @) D O_ _ Y): iYs1 464h. VR SECONDARY CONTAINMENT _ ❑ 1.S•mwa.- 0-4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.O'rHER(Specify): 464hI. ..__._._____._..___...._...______.__.._._....._.____..__..._.___._._-....._...._._____......._...,..___..._..__._..___..._.._._.__._.___._._..___..._.___._._-1. 111..-__.•..._..._......._...,._._. . VENT PIPING TRANSITION SUMP TYPE JQ 1.S1NGt.E WALL ❑ 2.DOUBLE WALL ❑ 90.NONE _464L �._._ _.__._..___.._....___ ._.______ ___.__._._.. .._-_...___...._._...__...____.._.._..._......._......_...._............._...._.__.___.__.......__....--1...1.....1......1._ .._._..1111_ __^ RISER PRIMARY CONTAINMENT f9 I.STEEL ❑ 4.FIBr:RGLASS D 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER�S ecify) 464J �i4f -.•....................._......___..._....___......_....._........__....., ._ -- •_....- _- _- -_ _- __._ •._._ . 5 RISER SECONDARY CONTAINMENT ❑ I.STEEL, ❑ 4.FIBERGLASS _❑ 10.RIGID PLASTIC_ ❑ 90.NONE ❑ 99.0•1`1-11.•.11(Specify): 10/4 60.1 _ _ _ _ _ _ _ _ _ 46441. FILL COMPONENTS INSTALLED I.SPILL.I3UCK''_' (�`3.S'1111KGR PLATLIBO"I"i'OM PROTEC'T'OR .811 4.CONTAINM13N'I'SUMP 451o:c' VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE 1.SINGLE WALL ........ . _ CONSTRUCTION MATERIAL ❑ 1.STEEL A 4.FIBERGLASS D 10.RIGID PLASTIC ❑ 99.0'1'1.11'311(Specify) 169c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL.ANODL•(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448- IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is (rue, accurate,and in full compliance with legal requirements APPLICANT SIGNATURE % l' DATE ` 470' APPLICANT NAME(print) 471' APPLICANT TITLE472. UPCF UST-B Rev.(12/2007)-1/Z www.unidoes.org