COMPLIANCE INFO_2005-2012 - Laserfiche WebLink

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CJ UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK '',,nnJ OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) AJC TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only thissec'on and Sections I,IL III,IV,and IX below) 430 ❑ 1.NEW PERMIT C33.RENEWAL PERMIT 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 430b I"`FACILITYINFORMATION FACILITY ID#(Agency Use Only) a2 P BUSINESS NAME(Same as FAC114TY NAME or DBA-Doing BusinessAs) 3 KP_ S' &I C'._S `' L [ u o r- BUSINESS SITE ADDRESS / 1 I ©® 103 CITY O 104 `-� H.TANKDESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 T CONFIGURATION:THIS TANK IS 434 Ir 1.A STAND-ALONE TANK [12.ONE IN A COMPARTMENTED UNIT. Compide one PAP for each cmipatincat in the umL DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 III:TANK USE'AND CONTENTS' TANK USE h Ia.MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ lc.AVIATION FUELING 439 [33.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(IndWa Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: Ia.REGULAR UNLEADED ❑ la MIDGRADE UNLEADED ❑ 1b.PREMIUM UNLEADED 440 ❑ 3.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-PETROLEUMS ): 440b IV TANK CONRIfiGIIQN TYPE OF TANK ❑ 1.SINGLE WALL RL 2.DOUBLE WALL ❑95.UNKNOWN 443 PRIMARY CONTAINMENT 0 L STEEL ❑ 3.FIBERGLASS [16.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ t.STEEL N3.FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE .❑95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION 0 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT ja 3.FILL TUBE SHUT-OFF VALVE 452 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT Y PIrOI L7GT l�T ASTE P PIl�IG +E} i Ic PIPING CONSTRUCTION ❑1.SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE X 1.PRESSURE ❑2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑4.SAFE SUCTION[23 CCR§2636(x)(3)] 458 PRIMARY CONTAINMENT ❑ L STEEL Iff 4.FIBERGLASS [18.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑95.UNKNOWN ❑99.OTHER(Specify): 464c PIPING/IURBINE CONTAINMENT SUMP TYPE OL 1.SINGLE WALL [12.DOUBLE WALL ❑90.NONE 464d VI:VENT,VAPOR;RECOER )A1tISERf IEIPE PIPI�IOOk�iSRUCI© :; VENT PRIMARY CONTAINMENT Ll 1.STEEL P9 4.FIBERGLASS U 10.RIGID PLASTIC U 90.NONE U 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.FORE❑ 99.OTHER(Specify) 464f 464t1 VR PRIMARY CONTAINMENT ❑ 1.STEEL Pd 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 4648 464 t VR SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 0 2.DOUBLE WALL 90.NONE 464L RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC NONE 0 99.OTHER(Specify) 464) 4647 RISER SECONDARY CONTAINMENT L STEEL 0 4_FIBERGLASS 0 W.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464k 464kt FILL COMPONENTS INSTALLED 1.SPILL BUCKET ❑ 3.STRIKER PLATOBOTfOM PROTECTOR 0 4.CONTAINMENT SUMP 451ao VIL UNDER'.DISPENSER COIiFFll![1VIE1�T;(URC�<; CONSTRUCTION TYPE 1.SINGLE WALL ❑?-DOUBLE WALL ❑3.NO DISPENSERS ❑ 90.NONE 969a CONSTRUCTION MATERIAL ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑99.OTHER 469b-c STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑4.WRESSM CURRENT 6.ISOLATION 448. _. �. IX.`APPLLeA1�T sIGN�!`IURE _ CERTIFICATION:I certify this U systemiskompatible with the h oas substance stored and that the information provided herein is true,*Ccumte, and in comp ce with legfil requirements. APPLICANT SIGNA DATE q J 470 APPLICANT NAME(print) r 1 /�G 471. APPLICANT TITLE n G ^, 477 .._,_. UPCF UST-B-1/2 Rev.(17J2007)