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-6 #1 6iq (D UNIFIED PROGRAM CONSOLIDATED FORM I- UNDERGROUND STORAGE TANK V 0 OPERATING PERMIT APPLICATION-TANK INFORMATION(One`t`orm p (1S rrj TYPE OF ACTION (Check one item only. F rST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 430 El1.NEW PERMIT a 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 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) 1717 4 71 1 BUSINEPNA MME(Same as FACILITY NAM,F-or DBA-Doin Bus' s As)j 3 L BUSIMIMDDRESp /,_. ,�_ 103 1 CITY �+ 104 II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 / y ' ❑1.A STAND-ALONE TANK firJ Romfi2.ONE IN A COMPARTMENTED UNIT. ete one for each cmn em in the mtit. DATE UST SYS M INITALLED 435 TANK CAP ITY IN GALLONS a36 NUMBER OF COMPARTMENTS IN THE UNIT 437 t�!r PC> L M.TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ 1c.AVIATION FUELING 439 tT 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 ❑ lb.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 2L2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT X 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 Ef'7.STEEL+INTERNAL INING ❑ 95.UNKNOWN ❑ 99.OTHER (Sci ): 444a SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER [I7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(SE22!%): 445a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS 0 2.BALL FLOAT A0 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILb PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED [159-.2.DOUBLE-WALLEDOTHER 460 SYSTEM TYPE 1.PRESSURE 2. RAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464 ❑ 90.NONE 95.UNKNOWN [I99.OTHER(Specify): 464a SECONDARY CONTAINMENT El 1.STEEL 4.FIBERGLASS El 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b [190.NONE 5.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGITUR BINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 464d VI.VENT,VAPOR RECOVE (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC Rk90.NONE ❑ 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC NC905.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE Q I.SINGLE WALL Q 2.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 464j RISER SECONDARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED SPILL BUCKET Iffe3.STRIKER PLATEBOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT.(UDC) CONSTRUCTION TYPE VT SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL X4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448• IX. APPLICANT SIGNATURE CERT1!11!FXf N:I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, audio full com fiance with legal requirements. AP IC RE DATE470• "2-4- L y 1 APPL _ �' *fad a71. APPLICANT T }� an. UPCF USIMS-1/2 Rev.(12/2007)