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UNHUD t PROGRAMr Ir r FORM UNDERGROUND STORAGE TANK OPERATING P • TYPE OF ACTION (Check one item only. For an UST permanent closure or removal, complete only this section and Sections I, II, III, IV, and IX ❑ L NEW PERMIT ® 3. RENEWAL PERMIT [15. CHANGE OF INFORMATION n 6. TEMPORARY UST CLOSURE n 7. UST PERMANFNT CI.nRI IRF nN RTrE F1 R I IRT RFMOV AI. DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 430b FACUM.I1�II!Q FACILITY ID # (Agency Use Only) 1� BUSINESS N Salmi as F CILITY NAME BA -Doing Business As) 3 C 20 S BUS SS SITE AD S5103 C]Ty 104 LL ®l.i t z �i'r �` Met WIANK,DESS t1N TANK ID # 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 -r/+&j65-90/ . A STAND-ALONE TANK 7( e %% ,/ .0 2. ONE IN A COMPARTMENTED UNIT. C � <v C�' G� gomplate one M for wch cmnparmmo in the wait. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 Iwo r- «2 in . T USE' CO S ;. TANK USE ❑ la. MOTOR VEHICLE FUELING ❑ ]b. MARINA FUELING ❑ Ic. AVIATION FUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (todWes Used Oil) 5. EMERGENCY GENERATOR FUEL [HSC §25281.5(c)] 06. OTHER GENERATOR FUEL ❑ 95. UNKNOWN 999. OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la. REGULAR UNLEADED ❑ 1c. MIDGRADE UNLEADED ❑ lb. PREMIUM UNLEADED 440 47'3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS a 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM S 440a NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ❑ 11. OTHER NON -PETROLEUMS 440b .IZ : T .. , CONSTRUCTION :, TYPE OF TANK ❑ 1. SINGLE WALL 2. DOUBLE WALL0 95. UNKNOWN 443 PRIMARY CONTAINMENT 1. STEEL ❑ 3. FIBERGLASS 0 6. INTERNAL BLADDER 444 fj 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (S 444a SECONDARY CONTAINMENT ❑ 1. STEEL W3. FIBERGLASS [36. EXTERIOR MEMBRANE LINER [17. JACKETED 445 [190. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specifft 445a OVERFILL PREVENTION SUL AUDIBLE & VISUAL ALARMS E32.BALLFLOAT ❑ 3. FILL TUBE SHUT-OFF VALVE 452. 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT - v. I'RCII>tTCfi � FII'iNO CONSTRUCTION ` - = PIPING CONSTRUCTION ❑ 1. SINGLE-WALLED2. DOUBLE -WALLED [199. OTHER 460 SYSTEM TYPE E]1. PRESSURE ❑ 2. GRAVITY EQ. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION 23 CCR §2636(ax3)] 458 PRIMARY CONTAINMENT W 1. STEEL ❑ 4. FIBERGLASS 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT �l. STEEL [14. FIBERGLASS [I8. FLEXIBLE El 10. RIGID PLASTIC 4646 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464c PIPINGITURBINE CONTAINMENT SUMP TYPE 4MI. SINGLE WALL ❑ 2. DOUBLE WALLNZ.NONE 4644 g. irgs� ryr�g VI.: ' ; V R 3i' .. PIPE FII CONSTRUCTION . VENT PRIMARY CONTAINMENT 1. STEEL 4. FIBERGLASS Ll 10. RIGID PLASTIC 90. NONE 0 99.OTHER (Specify) 464e 467el VENT SECONDARY CONTAINMENT ❑ 1. STEEL 4. FIBERGLASS 10. RIGID PLASTIC ❑ 90. NONE 99.OTHER (Specify) 464f 464fl VR PRIMARY CONTAINMENT 1. STEEL ❑ 4. FIBERGLASS 0 10. RIGID PLASTIC 'K 90. NONE 99. OTHER (Specify) 4648 463 1 VR SECONDARY CONTAINMENT 0 1. STEEL ❑ 4. FIBERGLASS 10. RIGID PLASTIC 90. NONE 99. OTHER (Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 1. SINGLE WALL El 2. DOUBLE WALL W90. NONE 464i. RISER PRIMARY CONTAINMENT 1. STEEL 4. FIBERGLASS U 10. RIGID PLASTIC 90. NONE 99. OTHER (Specify) 463j 467'1 RISER SECONDARY CONTAINMENT 1. STEEL 0 4. FIBERGLASS 0 10. RIGID PLASTIC 0 90. NONE 0 99. OTHER (Specify) 464k 464k1 FILL COMPONENTS INSTALLED jr 1. SPILL BUCKET 3. STRIKER PLATEBOTTOM PROTECTOR OL4. CONTAINMENT SUMP 45la-c DTII. DISPENS ' 'CONTAI PV1' ' CONSTRUCTION TYPE ❑ 1. SINGLE WALL ❑ 2. DOUBLE WALL W3. NO DISPENSERS ❑ 90. NONE 469a CONSTRUCTION MATERIAL ❑ 1. STEEL ❑ 4. FIBERGLASS [I10. RIGIDPLASTIC ) 99.OTHER (Speci 469bc C.. STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT 6. ISOLATION 448. CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the Information provided herein is true, accurate, and in full Winpliance vft legal requirements. APPLICANT SIGNATURE DATE 470. 471' APPLICANT NAME (print) 67 APPLICANT TITLE . [ 472. �� ® V $/ A 4 t�'r UPCF UST -B -112 Rev. (1212007)