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07/14/2010 WED 13: 52 FAX 2094683433 SJC EHD 0003/004 Cq 7 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form 13 'UYI-) ITYPCOFAC11ON (Check one item only. for an UST permanent closure or removal.complete only this section and Sections 1,1t,111,IV,and iX below) 436 ❑ T.NEW PERMIT 0-3.RENEWALPERMTT Q 5.CHANGE OF INFORMATION ❑ 6.TLMPORARY USTCLOSURE ❑ 7.USTPERMANENI"CLOSURE ON SITE ❑ 8.U5T'REMOVAL DATE UST PERMANENTLY CLOSED: 4104 DATTi EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID It(Agency Use Oils) _ BUSINESS NAME(Same as FACILITY NAME or DBA- Ding Business As) 3 V t- BUSINESS STfEADDRESS 103 CItY pp S2Z� 144 2s s N� Q.TANK DESCRIPTION TANK ID ' 432 'TANK MANUFACTURER 433 TANK CONFIGURATION:THISTANKIS 434 L A STAND-ALONE TANK -#P � ❑2.ONE IN A COMPARTMENnso UNIT. Com a4ono ro(or cath eou emxi4 ihc,aril. DATE UST SYSTEM INST'ALi.ED 435 1 TANK CAPA TT IN QALLONS e34 NUMBER OF COMPARTM1fN"I'S IN THE UNiT 437 III.TANK USE AND CONTENTS i TANK USE I&-Ia.MOTOR VFA41CLE FULL M-. ' ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 tj ).Clil9M#C+V.PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Metwla Used Wt) ❑ 5.EMERGENCY GENERATOR FUFL IHSC 02111.3(c)) ❑6.OTHER GENERATOR I'Urt. ❑95.UNKNOWN ❑ 99.OTHER(Specify): - 4394 CONTENTS PETROLEUM: ❑ Ia.RLGISI.AR UNLEADED ❑ Ic.MIDGRAllE UNLEADED WIb.tmrmiUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.jE1'FUEI, ❑6.AVIATION GAS ❑8.PETROLEUM BLEND FUEL ❑ 9.OTHER PiiMOLC"UM (specify): -140a NON-PHROLEUM:❑ 7.USED OiL ❑ 10.FITIANOL ❑ 11.OTHER NON-PHTROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ?DOUBLE WALL ❑95.UNKNOWN 443 PRIMARY CON'TAINMCNT ❑ 1.STEEL 3.FIBERGLASS ❑6.INTERNAL BLADDrR 444 ❑ 7.STEEL+INTERNAL LINING ❑95.UNKNOWN [199.OTHER (S ify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER ❑7.JACKETED 445 ❑90.NONE ❑9S.UNKNOWN ❑99.OTHER(specify) 44U.: OVERFILL PREVENTION I.AUDIBLE&ViSUALALARMS ❑2.BALLFLOAT ❑3.FILL TUBE SHUT-OIT VALVE 451 4.TANK MEETS REQUIREMENTS FOR rXEMPTION FROM OVERFILL PREVENTION HQUIPMENr V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONST'RUCT'ION ❑i.SI,NGLE-WALLED C1.00111111-WALLED ❑99.OTT#ER 460 SYSTEM TYPE Wt.PRESSURE ❑2.GRAVITY ❑3.CONVENTIONAL SUCTION ❑4.SAFI:SUCTION 121 CCR#2616(4)(3) 454 PRIMARY CONTAINMENT ❑ t.STEEL W4.FIBERGLASS ❑8.FtX-XiBL.E ❑ 10.RIGID PLASTIC 464 ❑90.NONr; ❑95.UNKNOWN ❑99.OTHER(S cify): 4644 SECONDARY CONTAIN' ❑ 1.STIM. IA 4.FIBERGLASS ❑8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑90.NONE. El 95.UNKNOWN ❑99.OTHER(Specify): 464c PIPING(CURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL2.DOUBLE WALL ❑90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT I.STEEL 0 4.FIBERGLASS ❑ 10.RiGID PLASTIC ❑90.NONE ❑99.OTHER(Specify) tG4c 4640 VENT'SECONDARY CONTAINMENT Wt.STEM ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑90.NONE ❑99.0T'HER(Specify) 4641 464(1 VR PR IIKY CONTAINMENT I.STEL'L [14.FIBERGLASS 0 10.RIGID PLASTIC p 90.NONE ❑99.OT HER(Specify) 4645 4MCI VRSECONDARY CONTAINMENT 1.STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑90.NONII ❑99.OTHER(Specify) 464h 4601 VENT PIPING TRANSITION SUMP TYPE t.SINGLE WALL 2.DOUBLE WALL ❑ 40.VONT; 461i. RISER PRIMARY CONTAINMENT W 1.STEEL ❑4.FIBERGI-ASS 11 10.R1G1D PLASTIC ❑90.NONE [194).OTHER(Specify) 4641 464ii RISER SECONDARY CONTAINMENT 1.STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC p 90.NONE ❑99.OTHER(Specify) 464k 4601 FILLCOMPONENT'SINSTALiED LSPILLHUCKL'T 3.STR(KCRPLATE)BOTTOMPROTECTOR ❑4.CONTAINMENT SUMP 1514c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ I.SINGLE WALL 2.DOUBLE,WALL ❑3.NO DISPENSERS ❑90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑".OTHER(Specify) 469b-c ViII. CORROSION PROTECTION STEEL COMPONENT PROTECTION W2.SACRIFICIAL ANODC(S) ❑ L IMPRESSED CURRNT ❑6.ISOLATION 443. UL APPLICANT SIGNATURE CF.trl'IFICA'TION:i certify that tkis UST system is compatible with the haurdous substance stored and that the information provided herein is true,accurate; j and in fall comp4aAe with is at requirements. APPLICANT SIGNATURE DATE ( � ' c7' 474 5. APPLICANT NAME'(print) ! r 471. APPLICANT TITLE 4r-. '' UPCF UST--B-112 Rev.(12!2007) ��