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r, tn �� IED PROGRAM CONSOLIDATED FORW UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION -TANK INFORMATION (One form per UST) TYE----ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11,Ill,!V,and!X below) �(J s� 0 ❑ 1.NEW PERMIT D1 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION FJt �J Q ❑ 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) - - C" C 1 BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. Cv UM r�V M S� BUSINESS SITE ADDRESS � /� 103. CITY �^ Cq G* 9 S 3-7 / 104. 3•�• ch`A l l � /T 4 ' II. TANK DESCRIPTION TANK ID#� 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. ❑ 1.A STAND-ALONE TANK Complete one page for each IN 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. - 9 6 b o a Two III. TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] 6 OTHER GENERATOR FUEL ❑ 95_UNKNOWN ❑ 99.OTHER(Specify): 439a. ------ ----._.._..._...----...._.. _.._..._.._.._....-------- -_.__.._..-----.._..._..._....._._.....--.... -"-------------.___.."_.._..._._........-- CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ 1b.PREMIUM UNLEADED 440. IM 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 ® I.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN [1_"-99.OTHER(Specify): 444a. SECONDARY CONTAINMENT ❑ I.STEEL M3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445x. --...__. ....._.._. --- OVERFILL 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 E 1.SINGLE WALL 9 2.DOUBLE WALL 0 99_OTHER 460. --._ _.._.. -- -- ---._ ........---.- - --- .._......---- S_YS_TEM_T_YPE ®_1.PRESSURE [12.GRAVITY 0._3.CONVENTIONAL SUCTION- [1 4.SAFE SUCTION[23 CCR§2636(ax3)] 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 ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. ❑ 90.NONE [195.UNKNOWN ❑ 99.OTHER(Specify): a6ac. -___..._..----__--_._...__.................-._.___._..._..___....._.._-__ _..._.._._.__._-- PIPING/TURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644. VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ($4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): a64el. . ---- --------- ... ---- ------ --------.. .............. 46417. VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 19 90.NONE ❑ 99.OTHER(Specify): 464171. .-_..._. --- -""--- 464g. VR PRIMARY CONTAINMENT ❑ 1.STEEL )W 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90 NONE ❑ 99.OTHER(Specify): 464 1 --- - ---- -- ---.. _--- ------ -- - _.._ VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC .® 90.NONE ❑ 99.OTHER(Specify): 464h1. ----..._......._...._....- -- ------------------..__.._......................._...._.....__._... VENT PIPING TRANSITION SUMP TYPE ❑ L SINGLE WALL C32.DOUBLE WALL ®90.NONE 4641. 46 . RISER PRIMARY CONTAINMENT ® 1.STEEL C] 4.FIBERGLASS ❑ 10.RIGID PLASTIC C] 90.NONE ❑ 99.OTHER(Specify): 46441. RISER SECONDARY CONTAINMENT [11.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC �90.NONE [199.OTHER(Specify): 464kl. FILL COMPONENTS INSTALLED JR 1.SPILL BUCKET R 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE 1.SINGLE"WALL _ 2.DOUBLE WALL ❑ 3.NO DISPENSERS- ❑"90_NONE 469a- ---..__. 4696. CONSTRUCTION MATERIAL ❑ 1.STEEL ® 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 com lianncce470. c�with legal requirements APPLICANT SIGNATURE DATE APPLICANT NAME(print) f��'r T S.SA W�14 L.( 471' APPLICANT TITLE J3 USI Al tSs D ur M 472" UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org