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07/14/2010 WED 13: 52 FAX 2094683433 SJC EHD 2003/004 y; UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per usT) TYPE Oh ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,11,111,IV,and IX W-ow) 00 ❑ 1.NEW PERMIT' 3.RENEWAL PEItMI"1' ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSUItE ❑ 7.UST PERMANENT CL)SUIkE ON SITE ❑ 8.UST REMOVAL DATE USI'PEItMANI NT LY CLOSL'D: 4i.i 1 DATE EXIS TING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILY!'Y ID tl(Agency Use Onh) _ BUSINESS NAME(Sarno as FACILI'T'Y NAME or DBA-T oing Business As) 3 BUSINESS SITEADDRL'SS 101 Cl'CY /lAPO 522-(a 104 2s s til II.TANK DESCRIPTION "TANK ID I - ' O 432 TANK MANUFACTURER 433 'TAW coNr-IGURATION: THIS TANK IS 434 /A`�' '' F'' {p 1.A STAND-AI.ONE"I'ANK l/1" I I �fG ❑2.ow.INA COMPARTMENTED UNIT. ////1111��• ___� Coloplac oitc me for each com a"'Hou in Ute unit. DA'Z'E UST SYSTEM INSTALLED 435 TANK CAPACITY IN 'ALLONS 436 NUMBER OF COMPARTMF�NTS IN THE UNIT 43? IIIl."TANK USE AND CONTENTS TANK USERI&MOTOR VFI41CLE'PUI LING [IIb.MARINA FUELING C3 Ic.AVIATION FUEIANG 439 3.CHEMICAL PRODUCTSTORAGE ❑ 4.TEAZARDDIJS WAS'1'1 (6rcluda Us,dOi0 ❑ 5.EMERGENCY GENERATOR FURL tIlSC§25281.5(c)i ❑ 6.O'1.14ER GL%NTsRATOR FULL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ ta.REGUI.AR UNLLAOL^-D ❑ Ic.MIDGRADB UNLEADED ❑ 1b.PREMIUM UNLEADED 440 3.DIESEL ❑ 5.JET FUEI, ❑ 6.AVIATION GAS R.PETROLEUM DLIsND FUEL ❑ 9.0THER PETROLEUM (S recif I: 440a NON-PE 1'ROLEUNI:❑ 7.USED OIL ❑ 10.E7l1ANOI. ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION -TYPE OF TANK ❑ 1.SINGLE WALL 12.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ L STEEL 19L3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL.t.INTERNAL LINING ❑ 95.UNKNOWN ❑99.0 rimR (Specify): '144a SECONDARY CONT'AINMEN'T ❑ L STEEL rIBERGLASS El0.EXTERIOR MEMBRANE LINER ❑ 7.JACKuED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OT11Ell(Specify) 445a OVERFILL PREVENTION t.AUDIBLE&VISUAL ALARMS El 2.BALL FLOAT ❑ 3.FILL TUBE SI IUl'•OFF VALVE 452 4.TANK MEETS REQU)REMFSNTS FOR ExumPTION FROM OVERFILL PREVENT ION IEQUII;MrN'C V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED C'.DOIIBI.E-WALLED ❑99.0'['HER 460 SYSTEMTYPE 1.PRESSURE ❑2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑4.SAFE SUCTION(23CCR:206(al(3)1 458 PRIMARY CONTAINMENT ❑ 1.STI:IiL W4.FIBERGLASS ❑8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑95.UNKNOWN ❑99.on-trR(Specify): 464a SECONDARY CONTAINMENT ❑ L S'CL'lil, 47113MIGLASS ❑8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑w NONE 95_UNKNOWN ❑99.OTHER(Specify): 461k PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ t.SINGLE WALL &2.DOUBLE WALL ❑ 90.NONE 46-Id VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT yj I.S'rl:)-.L, ❑4.13 RGI.ASS ❑ l0.RIGID PLASTIC ❑90.NONE ❑997T HER(specify) •164, 4640 VENT SI5CONDARY CONTAINMENT 1.STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTIII'R(Specify) 464f 4601 VR NUMARY CONTAINMENT I.WEE.. ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4464 VRSFCONDARY CONTAINMENT L STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.0"1'HLR(Specify) 4641, 464h1 VENT PIPING TRANSrNoR SUMP TYPE L SINGLE WALL 2.DOUBLE WALL. ❑ 90.NONE 4641. RISER PRIMARY CONTAJNMENT F S'IT EL ❑4.FIMRGLASS 11 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(S(mcify) 4641 46411 RISER SECONDARY CONTAINMENT I.STEEL ❑4.FIBERGLASS ❑ l0.RIGID PLASTIC ❑ 90.NONE 99.01HER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPILL I3UCKF:T ❑ 3.STRIKER PL.ATEiB0'ITOM PROTECTOR ❑4.CONTAINtMEN C SUMP 1513-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ I.SINGLE WALL 3.DOUBLE WALL ❑ 3.NO DISI'IiNSERS [390.NONE 469a CONS'I'RL'Cl'ION A4A'CERIAL ❑ I.S'Ci Ei. 4.FIBERGLASS ❑ 10.RIGIO PLASTIC ❑ 99.OT HrR(Specify) 469b•c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION 2.SACRTFIC)AI.ANODE(S) ❑4.IMMIESSED CURREN'r ❑ 6.ISOLATION 443 IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this USX system is compatible with the hatalydons substance stored and that the information provided herein is trttclwoeurate, and in 6dl cum with legal requirements. APPLICANT SIGNATURE DATE 170' L, APPLICANT'NAMI's(grin ®L,,y � a!1' APPLICANT TITLE �� w'• t"' UPCF UST I -I3-1/2 Rev.( 2/2{p yi