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07/14/2010 WED 13: 52 FAX 2094683433 SJC EHD 12003/004 go 44 ('r 7-ZZ%6 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per USI') TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,compketc only this section aml Sections 1,It,III,IV,and IX below) 430 ❑ 1.NEW PERMIT ❑ 3.ItENtEWALPEltMIT ❑ S.CHANGEOFINFORMAI'ION 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CIX)SURE ON SITE ❑ 8.UST RCMOVAL DATE UST PERMANENTLY CLOSED: 4303 iwn:EXISTING UST DISCOVERED: 430b 1. FACILITY INFORMATION FACit.fi'Y ID A(Agency Use Ondt) I BUSINESS NAME(Same as FACILITY NAME or D13A- Ding Busitu:ss As) 3 v R-�rr 3USIN2CI- SS //� ,otSs1 ;%47 � � S22- CI.TANK DESCRIPTION TANK ID Y 32 TANK MANUFACTURER 433 TANK C.ONFtGURATION THISTANK IS 414 3 uL- �.A EINACOMNC1 mr �' ❑2.UNf:(N A CUMI'ART'A4ENTEll UNIT. Com t"on4 Pago for cxh mu in On trait. DAI'E UST SYSIT.M INSTALI.I:D 435 TANK CAPA2'Y IN 'ALLONS 436 NUMBER OFCOMPAWI M NTS IN'1'H1-UNIT 437 III.TANK USE AND CONTENTS TANK USE la MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 419 3.CHEMICAL.PRODUCT STORAGE ❑ 4.14AZARDOUS WASTr(Includes Uscd 010 ❑ 5.EMERGENCY GENERATOR FULL Insc 42=1.5(0) ❑6.0T HI-R GENERATOR FUr1. ❑ 95.UNKNOWN ❑99.OTHER(Specify): 439a CONTENTS PETROLEUM: '91Ia.REGULAR U14LEADED ❑ )c.MIDGRADE UNLEADED' ❑ 1b.PREMIUM UNLEADED 440 3.DIESEL ❑ 5.Jirr FUE1, ❑6.AVIATION GAS ❑S.PETROLEUM BLEND FUEL ❑ 9.OTIIER PIiTTtOLEUM (S if): '1403 NON-PETROLEUM:[] 7.USED OIL ❑ 10.rTHANOL ❑ 1].OTHER NON-PI:fROLEUM(Specify): 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL [195.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL 3.11BERGLASS ❑6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LENING ❑95.UNKNOWN Q 99.OTHER (Spot ): 4442 SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER ❑7.JACKETED 445 ❑ 90.NONE El 9S.UNKNOWN ❑99.OTHER(Specilyy 4453 OVERFILL PREVENTION I.AUDIBLE&VISUAL ALARMS 0 2.HALL FLOAT ❑ 3.FILL TUBE SHUT'.OIT VALVE 431. 4.TANK MEETS REQUIREMENTS FOR rXEMPTION FROM OVERFILL PRrVEN ION I:QUBSmEw V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SiNGLE•WALLED Itl DOUBLEAVALLED ❑99.OVER 460 SYSTEM TYPE aj.PRESSURE ❑2.GRAVITY ❑370-NVENTIONALSUCfION ❑4.SAFE SUCTION 123 CCR#26 ax)) 45R PRIMARY CONTAINMENT ❑ 1.STEEL W4.FIBERGI.ASS ❑B.fLL•XIBLE ❑ 10.RIGID PLASTIC 464 ❑90.NONE ❑95.UNKNOWN ❑99.0?14ER(Specify): 4641 SECONDARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS ❑&FLE3XIBLE ❑ 10.RIGID PLASTIC 464b ❑90.NONE 95.UNKNOWN ❑99.OTk4ER(Specify): 464c PIPINGJ(URBINE CONTAINMENT SUMP TYPE Q L SINGLE WAL.t. W2.DOUBLE WALL ❑W NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS ❑ 10.RLGID PLASTIC ❑90.NONE 99.GTltL•R(Specify) 464e 4wcl VENT SECONDARY CONTAINMENT 1.STEEL Q 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑99.OTIJER(Specify) 464( 4640 VR PRIMARY CONTAINMENT Vt1.STEEL ❑4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NOM3 ❑99.OTHER(Specify) 4645 464 l VR SECONDARY CONTAINMENT 1.57T:Ei ❑4.FIDERCi AS5 ❑ lo.RIGID PLASTIC (:190.NONE Q 99.OTIIL•R(Specify) 4641 awn( VrNT P(PLNG TRANSITION SUMP TYPE 0 t.SINGLE WALL 2.DOABLE WALL ❑90.NON]. 464i. RISER PRIMARY CONTAINMENT 1.STEEL ❑4.FIBERGLASS 10.RIGID PLASTIC 0 90.NONE ❑99.OTHER(Specify) 464i 464i1 RISER SECONDARY CONTAINMENT I.STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 4Wk 464u1 FILL COMPONENTS INSTALLED I.SPIT-L BUCKET 3.STR(KI:R PLATf1BOTTOM PROTECTOR ❑4.CONTAINMENT SUMP 4 64kl VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ I.SINGI.C•WALL 3.DOUBLE WALL ❑3.NO DISPENSERS ❑90.NONE 4693 CONSTRUCTION MATERIAL ❑ 1.STEEL M 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ ".OTHER(Specify) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION 2.SACRIFICIAL.ANODE(S) ❑4.IMPRESSED CURRENT ❑6.ISOLATION 44. IX, APPLICANT SIGNATURE CF101FICATION: I certify that this UST em is compatible With the haurdoas substance stored and that the information provided herein Is true,accurate, and in full compliancecomplianceytA is at requirements. APPLICANT SIGNATURE DATE 7 r 1 -23 APPLICANTNAME(print) 411. APPLICANT"CC E � ��L1/L r tar. t72• UPCF UST-B-1/2 Rev.(1712007)""