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A0k (0 IED PROGRAM CONSOLIDATED FORW UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION -TANK INFORMATION (One form per UST) Y;EACTION (Check one item only. For a UST closure or removal,complete only this section and Sections!,11,Ill,IV,and!X below) 711 Q/0. RMIT ,® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ((// ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a. I DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 3 r BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3 N-t-R Y 19 t4it-T• (!;-A.5 ova D BUSINESS SITE ADDRESS 103. CITY104. II. TANK DESCRIPTION TANK ID# 432' TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434' ,9 1.A STAND-ALONE TANK Complete one page for each A I� S S Z` �� ' ` ❑ 2.ONE IN A COMPARTMENTED UNIT compartment in the unit. DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. III. TANK USE AND CONTENTS TANK USE (S la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc.AVIATION FUELING 439' ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)1 ❑ 6.OTHER GENERATOR FUEL -� 95.UNKNOWN - ❑ 99_OTHER(Specify): 439a. CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440. Id 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440a. ......_..--- _ -- ---- ---... --- - ----- --- _..._ _.._...- NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL 95.UNKNOWN 443' PRIMARY CONTAINMENT 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444' ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN [199.OTHER(Specify): 444a. SECONDARY CONTAINMENT ❑ 1.STEEL ,�3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER [:1 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWNC]99.OTHER(Specify): 445x. _ - - RF ----- OVEILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452' ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 99.OTHER 460. -----._._._.._..._._..._....---.._.._._..._..._...........----- --._.._.._........._.._..--- ---------................................ ------- SYSTEM TYPE l_PRESSURE 0-2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458. PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a- .... -------- ----- ._......_...._.. _.........._._......-- _. -_._._.._._.._..------ SECONDARY CONTAINMENT ❑ 1.STEEL ,R 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d. VI. VENT,VAPOR RECOVERY (VR) AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL IR 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464el. -------.._..------------._._.._......................__..._.- --- ........_........------ -- -- VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS , 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER464E (Specify): 464f1. 464g. VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC El 90.NONE ❑ 99.OTHER(Specify): 464 t VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS i� 10.RIGID PLASTIC 01 90.NONE ❑ 99.OTHER(Specify): 464hl. -----...- - ------- ---- ..............----..-.------ --........_....----...._..__._......._..--..._..__........_.._.._......_..-------- VENT PIPING TRANSITION SUMP TYPE ❑ L SINGLE WALL d 2.DOUBLE WALL 90.NONE 46ai. RISER PRIMARY CONTAINMENT ® 1.STEEL El 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [199.OTHER(Specify): g6gj RISER SECONDARY CONTAINMENT [I1.STEEL [14.FIBERGLASS 10.RIGID PLASTIC 09 90.NONE [199.OTHER(Specify): 464k1. FILL COMPONENTS INSTALLED L SPILL BUCKET ON 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE 1.SINGLE WALL [12_DOUBLE WALL_ ❑ 3.NO DISPENSERS C190_NONE 469a. ---- -.......----- -- - ---------- ---- --- --- 469b. CONSTRUCTION MATERIAL ❑ 1.STEEL J.4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448' IX. APPLICANT SIGNATURE 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 compliance with legal requirements. APPLICANT SIGNATURE � G�� k A.,- DATE 470. APPLICANT NAME(print)7�a&A-MOTI��T Sl N S H S•r• v/)f4 APPLICANT TITLE Id k-3 S) 472 UPCF UST-13 Rev.(12/2007)-1/2 www.unidocs.org