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IFIED PROGRAM CONSOLIDATED FO UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) 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 below) 430 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT M.5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: a.oa DATE EXISTING UST DISCOVERED: 430b I FACILITY INFORMATION FACILITY ID#(Agency Use Only) �. BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 BUSINESS SITE ADDRESSto CITY d na, CAM 2� MAW+e-A M.TANK`'DESCRIPTION TANK ID#T� O q��10 3 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 ,...._-. . Ps, W.A STAND-ALONE TANK ❑2.ONE IN A COMPARTMENTED UNIT. D Complete one a for each eom arment in the unit. TE US TEM STALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER 0 COMPARTMENTS IN THE UNIT 437 �'Zo ODO 777 ;III TANK USE AND,CONTENTS TANK USE Ia.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ S.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERA OR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: 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 TANKCONSTRUCTION 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 ❑ 99.OTHER (S cify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL ❑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 Ur 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-WALLED .DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY ❑3.CONVENTIONAL SUCTION 4.SAFE SUCTION[23 CCR§2636(.)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL rX4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 9 .UNKNOWN [1 99.OTHER(Specify): 464a SECONDARY CONTAINMENT El1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGiTURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑2.DOUBLE WALL Gr90.NONE 4644 a ".' VI VENT,VAPORRECOyE (VR)AND RISER%FILLPIPE`PIPING'GONSTRUCTION .,. VENT PRIMARY CONTAINMENT ❑ 1.STEEL Eff 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT I.STEEL ❑ FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f VR PRIMARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS El 10. 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464g 4640 VR SECONDARY CONTAINMENT 571'-'STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑2.DOUBLE WALL 90.NONE 4641 RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC PQ 90.NONE ❑ 99.OTHER(Specify) 464j RISER SECONDARY CONTAINMENT ❑ 1.STEEL [1464'1 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464k FILL COMPONENTS INSTALLED 1.SPILL BUCKET El3.STRIKER PLATE/BOTTOM PROTECTOR El 4. 4.CONTAINMENT$UMP 451a-c VII:.UNDER.DISPENSERCONTMNMENT( IDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL M 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL. 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bs :VIII. CORROSI0I�I;PROTECTION `. STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑4.IMPRESSED CURRENT if 6.ISOLATION 448. IIX. 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 lice with legal requirements. APPLICANT SIGNATURE u 2 azo. APPLICANT NAME(print) a 471. APPLICANT TITLE 472• MkA%01 UPCF UST-B-1/2 Rev.(12/2007)