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mri UNIFIED PROGRAM CONSOLIDATED FORM ; l u UNDERGROUND STORAGE TANK ke V OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections I,A III,IV,and IX below) 430 ❑ 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: a'"h I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) - - ,C 1 BUSINESS NAME(Same Facility Name or�DRA-Doing Business As) 3 G- _ IV BUSINESS SITE ADDRESS TY W41°3. CI II. TANK DESCRIPTIO TANK ID# `bo�-� 432. TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434. �<�0✓� (Old ❑ I.A STAND-ALONE TANK Complete one page for each ❑ 2.ONE IN A COMPARTMENTED UNIT compartment in the unit. DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437 III. TANK USE AND CONTENTS TANK USE ❑ la MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ lc.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEI,, C§25281.5(c)] _ ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN 99.OT-IER(Specify):/d/ojor Ot 439, CONTENTS PETROLEUM: ❑ la REGULAR UNLEADED ❑ Ie.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL W 9.OTHER PETROLEUM(Specify): /$"yI/L/J £"fes a t E>;/ 440& ...................... NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION TYPE OF TANK SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN _ 443 PRIMARY CONTAINMENT 9 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL [13,FIBERGLASS ❑ 6.EXTERIOR MEMBRAU4 LINER ❑ 7.JA D 445. ❑ 90.NONE ❑ 95.UNKNOWN 99.OTHER(Specify): jfer2c t 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 WALL ❑ 2.DOUBLE WALL ❑ 99.OTHER . __._ 460._ SYSTEM TYPE ❑ 1.PRESSURE [12.GRAVITY jj 3.CONVENTIONAL SUCTION [14.SAFE SUCTION 23 CCR 263 a 3) 458- PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): _ 464a SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. ❑ 90.NONE ❑ 95.UNKNOWN jj_99.OTHER(Specify): �_ _ r_-''G1j,1• _�` PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL [14.FIBERGLASS [I10.RIGID PLASTIC [190.NONE ❑ 99.OTHER(Specify): 464e VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4"ffl.. VR PRIMARY CONTAINMENT [11.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464464 64 e h. VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS [I10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464h VENT PIPING TRANSITI64 SUMP TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464 RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS [110.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4_4j. RISER SECONDARY CONTAINMENT ❑ 1.STEEL [14.FIBERGLASS [110.RIGID PLASTIC [190.NONE ❑ 99.OTHER(Specify): �j FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATEJBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a-c. VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC [199.OTHER(Specify) 69b VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448 IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this U T system is compatible with the hazardous substance stored and that the information provided herein is true, accurate and in fu com fiance with legal requirements. APPLICANT SIGNATURE DATE 470. 8- C) APPLICANT APPLICANT NAME(print).-, 471. APPLICANT TITLE f�- 472. UPCF UST-B Rev.(12/2007)-112 www.unidocs.org