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Am ler IED PROGRAM CONSOLIDATED F09 _ UNDERGROUND STORAGE TANK �) OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE,OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 4301 ❑ 1.NEW PERMIT 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430x. I DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ _ �,' OZ 5 1 BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. q4 -PUroi BTJSINESS SITE APDRESS 103. CITY 104. ,3 3,50 N, Art ecialS+dc�k 'WANK DESCRIPTION _. TANK ID# 432 TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. K-pi'-T It 1.A STAND-ALONE TANK Complete one page for each 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. 2-D n l- 1 ZiGc�n III: TANK USE AND CONTENTS TANK USE ff la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Ic.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 [199.OTHER(Specify): 439a. ................................................_......._._........ ---........................-... ....__...-----.......- ............_..._.........._._.............._. CONTENTS PETROLEUM_ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440. 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440a. .................................................................._......-- ...---._............................-_........................._........................................................................._..._...........1111_-.....__....._..._....._.. .._.................. .......................... NON-PETROLEUM:❑ 7.USED OJL ❑ 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 ;R 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 441. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444a. . . _...._.._......................_...._...._._._._.......................---.......................................................................................................................................................................__..-.._.._...-._................................_._....................._................................ .................................................. SECONDARY CONTAINMENT ❑ 1.STEEL Ia 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): a45a. _........................................_....._.................._.__._.................................................................................................................................................................... -......_...._........_........_............... _. OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS S 2.BALL FLOAT ja 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT Y WASTE PIPING CONSTRUC'T'ION PIPING CONSTRUCTION ❑ 1.SINGLE WALL C&2.DOUBLE WALL ❑ 99.OTHER 460 _...._........_._...--- -._._............_.._........._..................._....._...................._._.........................................._.._....... --------...__..._.- .._..........._.................................._.._.................................................................................................__.....--- SYSTEM TYPE � - L PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION [3 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 ❑ 4.FIBERGLASS 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. ❑ 90.NONE ❑ 95.UNKNOWN 99.OTHER(Specify): 4644 -- ---......... ..-.........__................- ._......_........_.............._...................._..._..-1111. ------ ................... 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 }l 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e1,._. ...................................._..........................................._._.__........----.._.................................__...................._......................1' ................................................._.._......._.....__...._.._...............................- .._.__......_.._-._._._.............._........................................................ VENT SECONDARY CONTAINMENT [11.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [399.OTHER(Specify): 44 flf VR PRIMARY CONTAINMENT 1.STEEL 19 4.FIBERGLASS [310.RIGID PLASTIC ❑ 90.NONE [1......... 99.OTHER(Specify): ab4gt_ ..............................__..............__...---------.._..........__............._...._._..... ..............................................................................................---.........--.._.................._.._..----._..._._..----.--......................_..............._..........__....................................................................... NT 1 TEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify): 4641. VR SECONDARY CONTAINMENT ❑ .STEEL ❑ ❑ ❑ ( P fig) 464h 1. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 12:2.DOUBLE WALL ' 90.NONE 464' .........................__..-......_.................._...------....................-......................_...__._.._.....__....__._..............................................................................................._.._.......................---------.....__..........................................._......................................................................................................._....................................4 ;..... RISER PRIMARY CONTAINMENT X.I.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4641j.._ ......... . _... ....................._.__....._...._....-..----...__................................................._........................._..._......................_........_.................-------._..................................._....................__...._...................................................................... 464k. 11................-._._._. RISER SECONDARY CONTAINMENT ❑ 1.STEEL %4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464k1. _1.1.11. ....._...- ---._..._._..............................._...................._..._....................................................................................................._................................................................_._..----................_.__.._.........._._._................................ .............................................._.. FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR in 4.CONTAINMENT SUMP C&2 45la-c. VII. UNDER DISPENSER CONTAINMENT(UDC) ss CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS 0 90:NONI�j„' :::bra 469a. ..............__.._....__....._......-..__................................_._...__........- -- ._............. .._..........................................................._.................................................................._... ---.._.__...__...._......_.._.....- ---..._......._._...........................................__......................... CONSTRUCTION MATERIAL ❑ 1.STEEL V}4.FIBERGLASS ❑ 10.RIGID PLASTIC [399.OTHER(Specify) ;`'.: 469c. VIIL CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 19 6.ISOLATION 448. . ,APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided h s true, accurate,and in full compliance with legal requirements. APPLICANT SIGNATURE �` DATE 470 Z. G APPLICANT NAME(print) BeA.DDf 471. APPLICANT TITLE , /`f�Yc� �� SS�LI .5/i �76Cl� UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org