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{ ddmk UIWED PROGRAM CONSOLIDATED FOF1W 6J F� UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION -TANK INFORMATION (One form per UST) YPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections L 11,111,/V,and/X below) J/// 30 ❑ . 1.NEW PERMIT 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION l� 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) - - 7 C BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3' CO U,44 T24 1' A-+2T Cq.A S t,, v-vD BUSINESS SITE ADDRESS �N Ab 103. CITY -M t� C_ q5-3 ,7 / 104 II. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. Q 1.A STAND-ALONE TANK Complete one page for each �! G S �� c "�R ❑ 2.ONE INA COMPARTMENTED UNIT compartment in the unit. DATE UST SYSTEM INSTALLED 435• TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. 1.2000 a�>E III. TANK USE AND CONTENTS TANK USE ,(�la.MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ lc.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] 0 6.OTHER GENERATOR FUEL --- -0 95.UNKNOWN -------------- ---0 99_OTHER(Specify): 439a. NT COENTS PETROLEUM: A la.REGULAR UNLEADED ❑ la MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440. ❑ 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 Z2.DOLE WALL ❑ 95.UNKNOWN 443. ------------------- ...--- --- --- ....-UB----------- -- - ----- ------..__..._._. _ PRIMARY CONTAINMENT DF1.STEEL 10 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. 7 STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444x. SECONDARY CONTAINMENT ❑ 1.STEEL J3 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a. 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 ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 99.OTHER 460. SYSTEM TYPE_- _ � 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION 0 4.SAFE SUCTION[23 CCR§2636(8X3)]_ 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 ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. - PIP[NG/TURBINE CONTAINMENT SUMP TYPE JR L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4688. VI. VENT,VAPOR RECOVERY (VR) AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL H 4.FIBERGLASS ❑ 10.RIGID PLASTIC El 90.NONE ❑ 99.OTHER(Specify): 464el. VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC .® 90.NONE ❑ 99.OTHER(Specify): 464fl. ---.............._._..-------.._...._._..._..._...._..-------.--..._.._................-----._._._...--........--------__.__.....---------..._..._..__..------._.._. _ 464g. VR PRIMARY CONTAINMENT ❑ 1.STEEL �4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464 1. --- -- ------ .._......................._........__..__.._............__ --- .._.._... ---- ---- - -..... - --._.._..._.. _._.. VR SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 46 hl. ................- _._._.. . ._.._. _. - __...-- ---... _. -- VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 90 NONE 4M` a6aj. RISER PRIMARY CONTAINMENT JD 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 7 90.NONE ❑ 99.OTHER(Specify): 464'I' 464k. RISER SECONDARY CONTAINMENT C] 1.STEEL ❑ 4.FIBERGLASS E] 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 464k I' FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE 1 1.SINGLE WALL _____0..2_DOUBLE WALL - [ 3.NO DISPENSERS ❑ 90.NONE 469a - --- .. ...... _ _ ..... . . .. 469b. CONSTRUCTION MATERIAL ❑ I.STEEL ®4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT fj 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 9A/_ L-AllDATE b-))7-r � 470. APPLICANT NAME(print) -7A-p 4^j TI 7r S'/Nff�"hP4 APPLICANT TITLE 0-0�(/�j� &.45P7/(,',i SS • 472. UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org