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�KED PROGRAM CONSOLIDATED F cY✓} UNDERGROUND STORAGE TANK �,,`` 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 I,H,,III,IV,and IX below) •-z ❑ 1.NEW PERMIT3.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, L FACII:ITY INFORMATION FACILITY ID#(Agency Use Only) 1 BUS SS NAME(Same as Facili Name or DBA-Doing Business ifs) 3 /.1/( f�L Vv y BUS SITE A,pDRES �� 103. CTTy� _ _ � 104. th TANK DESCRIPTION TANK ID# 432• TANK MANUFACTURER 433• TANK CONFIGURATION:THIS TANK IS 434. �_ ❑ 1.A STAND-ALONE TANK Complete we page for each I .ONE IN A COMPARTMENTED UNIT comp-mmt in the unit. DATE UST SYSTJT�S4AT 435• TANK CAPACITY��NS 436• BER OF COMPARTMENTS IN THE UNIT 437• (/+ M. TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439. 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(maudes used oil) ❑ 5.EMERGENCY GENERATOR FUEL(Hsc§25281.5(c)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN [3,99.OTHER(Specify): 439& CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED jklb.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. . 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+INTERNALLINING ❑ 95.UNKNOWN [199.OTHER(Specify): 444& SECONDARY CONTAINMENT ❑ 1.STEEL JQ3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445& 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 PIP ENG CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 99.OTHER 460. SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(a 3) 458. PRIMARY CONTAINMENT ❑ L STEEL 9 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464& SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. ❑ 90.NONE Y5.UNKNOWN ❑ 99.OTHER(Specify): 464c. PIPINGfrmiNE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464(. W_ VENT,VACONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464e1. VENT SECONDARY CONTAINMENT El 1.STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE [199.OTHER(Specify): 464 flf VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464"8. VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 464bl. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL90.NONE 464i. RISER PRIMARY CONTAINMENT I.STEEL El 4.FIBERGLASS 1--] 10.RIGID PLASTIC [1'90.NONE ❑ 99.OTHER(Specify): q�1. RISER SECONDARY CONTAINMENT 1.STEEL ❑ 4.FIBE$G SS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 464kL FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451&-c. . V"ERDISPENSEk CONTAINMENT{UDC) CONSTRUCTION TYPE 1.SINGLE WALL [12.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE CONSTRUCTION MATERIAL ❑ 1.STEEL FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) ,,69c. VIII, .CORR+QSI N PItO ECT`iON r STEEL COMPONENT PROTECTIONl ❑ 2.SACRIFICIAL ANDD S ❑ 4.IMPRESSED CURRENT M6.ISOLATION �448• IX.' APPLICANT SIGNATURE CERTIFICATION: I ce t this UST system is compatible with the hazardous substance stored and that the information provided here; is- rue, accu compliance with legal requirements APPLICANT SIGNA _ DATE 1' 470' !t l APPLICANT NAW^ "'- ,-rr�� 471' APPLICANT TITLE ; 472. t� �1CJM ✓- t UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org