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IED PROGRAM CONSOLIDATED FO UNDERGROUND STORAGE TANK Z;�, �( OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. Fo a UST closure or removal,complete only this section and Sections 1,11,111,IV,and 1X below) )� r 30. ❑ 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: 430a DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 11 517-1 1 BUSIbLESS NAME(Same as Facili_/Naamee or DBA/-Doing Business As) 3 BUS E$ SITE ApDRESS 103. CITY \ loa. Ay 21��5z II. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. / D C`�,a % 'T ' �� ❑ 1.A STAND-ALONE TANK Complete one page for each ONE INA COMPARTMENTED UNIT compartment in the unit. DATE UST SYSTEMSTA ED 43s. TANK CAPACITY IN GALLONS 436. UMBER OF COMPARTMENTS IN THE UNIT 437. 1 0C)o ?� III. 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 ❑ 99.OTHER(Specify): 439a. CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ la 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. I . TANK CONSTRUCTION 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 0 95.UNKNOWN ❑ 99.OTHER(Specify_): 444a. SECONDARY CONTAINMENT ❑ 1.STEEL XL3.FIBERGLASS -------------------- ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445x. 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 .. C1SYSTEM TYPE 1.PRESSURE 2.GRAVITY ---- -------_..._.._........_.......----........._................._..--___._____ _-_ Q 3.CONVENTIONAL SUCTION _❑ 4.SAFE SUCTION[23 CCR§2636(6(a)(3)] 458. PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ----._- -----_.----0 90.NONE---........t5. � 95 UNKNOWN 99_OTHER(Specify): 464a. SECONDARY CONTAINMENT C11.STEEL .FIBERGLASS ❑ 8.FLEXIBLE [110.RIGID PLASTIC 4646. ❑ 90.NONE UNKNOWN ❑ 99.OTHER(Specify): 464c. 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 4.FIBERGLASS [110.RIGID PLASTIC [__190.NONE ❑ 99.OTHER(Specify): 464e1. VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS [310.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): g64fj. VR PRIMARY CONTAINMENT ❑ 1.STEEL �4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464g 1 VR SECONDARY CONTAINMENT [11.STEEL ❑ 4.FIBERGLASS [:110.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 464h1. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL W90.NONE 464i. RISER PRIMARY CONTAINMENT 1.STL [14.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) q�l: EE RISER SECONDARY CONTAINMENT ].STEEL ❑ 4.FIB%q SS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): q�j' FILL COMPONENTS INSTALLED QK 1.SPILL BUCKET 3.STRIKER PLATEIBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a-c. . UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a_ -- -------------- ---._..._.-.__._...---- --- -- --- 4696 . . CONSTRUCTION MATERIAL ❑ 1.STEEL FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I cc f t this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accura compliance with legal requirements. APPLICANT SIGNATLAdr DATE 470. I f � APPLICANT NAME %�' - 471. APPLICANT TITLE i' 472. UPCF UST-B Rev.(12/2007)-1/2 '-'7 www.unidocs.org