COMPLIANCE INFO_2005-2012 - Laserfiche WebLink

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0-0 1 C amu' UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK S�B� OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) ll TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this a and Sections I,u III,IV,and IX below) 430 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT .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..FACILTFY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as FAC ITY NAME or DBA-Doing Business As) 3 rQ.vJc"k'S C a- ct- L--,, o �' BUSINESS SITE ADDRESS '00 G, k-YJ dA m t 103 CITY 104 H.TANKDESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION.. THIS TANK is 434 56)fA r(AS C ® k.ONEANK IN A COMPARTMENTED UNIT. 1111 Complete one pw for each CMMMtFnC=intheUniL DATE UST SYSTEM INSTALLED 435 TANK CAPACY©ITGALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 bbOO 0 2 III:TANK USE AND CONTENTS. TANK USE 15kla.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ le.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Ioduft Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[ASC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 43% CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 1.3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ i 1.OTHER NON-PETROLEUMS : 440b `. Iv ,TAN,Ifi,CQNS, UCTIQN TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑95.UNKNOWN 443 PRIMARY CONTAINMENT CA 1.STEEL ❑ 3.FIBERGLASS ❑6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S ): 444a SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(specify): 445a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS El 2.BALL FLOAT K 3.FELL TUBE SHUT-OFF VALVE 452 ❑4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT . ', ` V PRI3DUC��=1�ASTE>PIPIl�IG CO�FSTKUCTIOl� =' PIPING CONSTRUCTION ❑1.SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OT'HER 460 SYSTEM TYPE I.PRESSURE ❑2.GRAVITY 17713.CONVENTIONAL SUCTION ❑4.SAFE SUCTION[23 CCR§2636(a 3)] 458 PRIMARY CONTAINMENT 0 1.STEEL ®.4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE 1395.UNKNOWN 1399.OTHER(SP-W): 464a SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specft 464c PIPING/TLURB INE CONTAINMENT SUMP TYPE I.SINGLE WALL ❑2.DOUBLE WALL ❑90.NONE 4644 VI VENT,VE4POR RPCOER (YR)Al♦ID ISERI.,FILL PIPE PIPILTG GONSTRUCTIO ' VENT PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE ❑ 9.OTHER(Specify) 464e VENT SECONDARY CONTAINMENT ❑ 1.STEEL 14 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f VR PRIMARY CONTAINMENT 464fl ❑ L STEEL � 4.FIBERGLASS ❑ l0.RIGIDPLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 464g VR SECONDARY CONTAINMENT 464 l ❑ 1.STEEL [�4.FIBERGLASS ❑ !0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4646 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL 464h1 ❑2.I)DUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT ® L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90:NONE 13 99.OTHER(Specify) 464) RISER SECONDARY CONTAINMENT '\ 1.STEEL 464 l ❑ 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 13 99.OTHER(Specify) 464k FILL COMPONENTS INSTALLED 0 1.SPILL BUCKET 0 3.STRQCER PLATF/BOTTOM PROTECTOR 464k1 4 CONTAINMENT SUMP 45la-c ' �II UNDER'DISPENSERCO.LAIINT" ': CONSTRUCTION TYPE 1.SINGLE WALL 4 ❑2.DOUBLE WALL ❑3.NO DLSPENS13tS CONSTRUCTION MATERIAL 13L STEEL ❑90:NONE 469a 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTIlER(Specify) 4 469 VIII CORROSIQN ERECTION`, �.,, ❑ 2. S) ❑4.IMPRESSED CURRENT 6.ISOLATION 448.SACRIFICIAL ANODE STEEL COMPONENT PROTECTION ( IX. APPLICAN CERTIFFCATION:I certify tha,tAMs US system is lmpatibie with the h7doussubsbnce stored and that the Information provided harem isunite, and in fkdreompliaske with nts. APPLICANT SIGNATURE \ DATE J 470. APPLICANT NAME(print) /r alt. APPLICANT TITLE W N e- v a72 r e r (Jl UPCF UST-B-V2 Rev.(1212007)