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3 lA4J 8�z5 110 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (one form per UST) <br /> TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 430 <br /> ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430& 1 DATE EXISTING UST DISCOVERED: <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use`Only) <br /> BU S NAME a as Facility Name or DBA-Doing Business As) 3. <br /> BUSINESS SITE ADDRESS 103. CITY/ 104. <br /> W ( Com(vo <br /> II. TANK DESCRIPTIO <br /> TANK iD# O 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. <br /> ❑ 1.A STAND-ALONE TANK Complete one page for each <br /> .5g� tnJ ell �tlDln IC ❑ 2'.ONE IN A COMPARTMENTED UNIT compartment in the unit. <br /> DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. <br /> M. TANK USE AND CONTENTS <br /> TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439. <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(includes Used oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] <br /> ❑ <br /> 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN .L99.OTHER(Specify): 439a <br /> CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ ]c.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADE 440. <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATI N GAS <br /> 42L❑ 8.PETROLEUM BLEND FUEL ' 9.OTHER PETROLEUM(Specify): Ll os p 44.0 <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ <br /> 11.OTHER NON-PETROLEUM(Specify): 440b. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK X1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN _ 443. <br /> PRIMARY CONTAINMENT ,9-1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444a. <br /> SECONDARY CONTAINMENT ❑ L STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 <br /> ❑ 90.NONE ❑ 95.UNKNOWN O.W.OTHER(Specify): CQ^Lrere- 445a <br /> OVERFILL PREVENTION ❑ 1.AUDIBLE 8c VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 4 1 <br /> 4W4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 99.OTHER . 460 <br /> SYSTEM TYPE _ ❑ 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2u36(ax3)] 458. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC MA <br /> ❑ 90.NONE _[1 95.UNKNOWN ❑ 99.OTHER(Specify): <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 461c. <br /> PIPING/CURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 <br /> VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ L STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC El 90.NONE [199.OTHER(Specify): 4�j <br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS [110.RIGID PLASTIC ❑ 90.NONE [199.OTHER(Specify): 464£1 <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464 e. <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS [110.RIGID PLASTIC [190.NONE [199.OTHER(Specify): 4664h1_ <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4641. <br /> RISER PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4 gi4j; <br /> RISER SECONDARY CONTAINMENT [11.STEEL [14.FIBERGLASS [110.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464j <br /> FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c. <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL [13.NO DISPENSERS [190.NONE 469a. <br /> -- - - 6 - <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4699cc. <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 4-44 <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, <br /> accurate,and in fu com liance with legal requirements. <br /> APPLICANT SIGNATURE DATE 410 <br /> APPLICANT NAME(print)< / / rte 471. APPLICANTTITLE ;ry`" SLr <br /> 472 <br /> UPCF UST-B Rev.(12/2007)-1/2 C-/ www.unidocs.org <br />