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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) VIE OF ACTION (Check one item only. For UST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 430 - .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: 410aI DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION D I* FACILITY ID#(Agency Use Only) _ _ I ] l(] 11 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 Gif- t sQ_d. n c� �t BUSINES ITE ADDRESS` 103 1 CITY 104 rG �0. 0?j, 'Tl cx/--` , C;� II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 Mr I.A STAND-ALONE TANK [12.ONE IN A COMPARTMENTED UNIT. C / Complete one page for each compartment in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 . III. ANK USE AND CONTENTS TANK USE ❑ Ia.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Ic.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 YC95.UNKNOWN ❑ 99.OTHER (SP �k eci 439a CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): iy < 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL CV95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ I.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 c"^ C.. ❑ 7.STEEL+INTERNAL LINING W5.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ L STEEL 4 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE UNKNOWN ❑99.OTHER(Specify): 445a 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 ❑L SINGLE-WALLED ❑2.DOUBLE-WALLED [199.OTHER G_. 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE 9jr95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGITURBINE 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 ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE &99.OTHER(Specify) 464e VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE� 99.OTHER(Specify) 46417 4 ❑ i_0• 464f1 VR PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [jr99.OTHER(Specify) 4648 w 464 l VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE E4 99.OYER(Specify) 464h 464h] VENT PIPING TRANSITION SUMP TYPE 0 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE �_/G, 4641. RISER PRIMARY CONTAINMENT L STEEL ❑ 4.FIBERGLASS E] 10.RIGID PLASTIC El / 90.NONE 99.OTHER(Specify) �46 RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 19199.OTHER(Specify)C 464k 464k1 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP i,_r . 451 a-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 4-_ !i 469a CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC CY99.OTHER(Specify) &;I-A,-, 469b-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 6- -- 448. IX. APPLICANT SIGNATURE y CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,Jwurati, and in full compliance with legal requirements. APPLICANT SIGNATURE DATE 47 APPLICANT NAME(prty' Y 471. APPLICANTS ITLE UPCF UST-B-1/2 Rev.(12/2007)"x"