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IED PROGRAM CONSOLIDATED FOjr 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 PERMIT5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE [17.UST PERMANENT CLOSURE ON SITE "8.UST REMOVAL DATE UST PERMANENTLY CLOSED: a3oa DATE EXISTING UST DISCOVERED: 4306 J.-FAIC ATIUN FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) R^ Tn'� 3 BUSINESS SITE ADDRESS CA l03 cz � co; ZIX ll tm CITY 104 CA CA H.TANKDESCRIPTION TANK ID# 432 /�`f TANK MANUFACTURER 433 TA CONFIGURATION: THIS TANK IS 434 ®y , -1 Al I) �,l [12 AST IN ALONE TANK COMPARTMENTED 1 O�� "' �ll ♦`d�W./ ❑2.ONE INA COMPARTMENTED UNfr. DATE USTSYSTEMINTALLED 435 Complete one eforewhcomamnentintheunit. TANK C ACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 '1 Lv Ok (0,00o M Wt o 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 6 ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ l .REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S eci ): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(S ecify): 4406 IV :TANKCONSTRUCTIO,N TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN qqj PRIMARY CONTAINMENT STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER -q44 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S ecify): 444a SECONDARY CONTAINMENT El1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER Z JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS [12.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452 El4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT :.: Vc PRODU T/WASTE PIPING CONSTRUCTION . PIPING CONSTRUCTION ❑I.SINGLE-WALLED W2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ .GRAVffY ❑ 3.CONVENTIONAL SUCTION 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ L STEEL Lff 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464 ❑ 90.NONE ❑ 9 .UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464 Q PIPING/I URBINE CONTAINMENT SUMP TYPE ❑ 1 SINGLE WALL ❑ 2 DOUBLE WALL 90.NO 4644 �C V10,-FENT,VAPORRECOVE (VR)A�TD:RISER%FILLPIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e VENT SECONDARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 464el ❑ 99.OTHER(Specify) 464f VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464g VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 4464h VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL 464hl ❑ 2..DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC 90.NONE ❑ 99.OTHER(Specify) 464j RISER SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464k FILL COMPONENTS INSTALLED 1.SPILL BUCKET 464k1 _. ❑ 3.STRIKER PLATEBOTTOM PROTECTOR ❑ 4:CONTAINMENT SUMP 451a-c VIL UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1 SINGLE WALL 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a 9.CONSTRUCTION MATERIAL ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b-c VIIL. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2 SACRIFICIAL ANODE(S) ❑4.IMPRESSED CURRENT K6.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 chmDR-an-ce"Nvitiklegal requirements. APPLICANT SIGNATURE DATE 2 20 470. APPLICANT NAME(print) 471' APPLICANT TITLE 472. i UPCF UST-B-1/2 Rev.(12/2007)