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Wmr Q' 6,ti�/- 2,3ZZ -Fl , <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 1,11,111,!V,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& I DATE EXISTING UST DISCOVERED: 4306. <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) _ _ 1 <br /> BUS S NAME(Same F ''ty Name or DBA-Doing Business As) ' <br /> BUSINESS SITE ADDRESS ^ 103' CITY 104 <br /> P5& Citi r <br /> H. TANK DESCRIPTIO <br /> TANK ID# d p/ n 432 TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. <br /> ❑ 1.A STAND-ALONE TANK Complete one page for each <br /> ❑ 2.ONE IN A COMPARTMENTED UNIT compar--t m the unit. <br /> DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. <br /> -2S0 <br /> III. TANK USE AND CONTENTS <br /> TANK USE ❑ la MOTOR VEHICLE FUELINGlb.MARINA FUELING ❑ 1c.AVIATION FUELING 439. <br /> ❑ 3.CHEMICAL PRODUCT STORAGE HAZARDOUS WASTE(Includes Used Od) [1 5.EMERGENCY GENERATOR FUEL(HSC§25281.5(c)] <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439& <br /> CONTENTS PETROLEUM: ❑ la REGULAR UNLEADED ❑ I c.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440. <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): .sit 4°?t 440& <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK W L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 <br /> PRIMARY CONTAINMENT CE�-1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99 OTHER(Specify): 444& <br /> SECONDARY CONTAINMENT ❑ 1.STEEL [13.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE INER El7.JACKETED 445 <br /> [190.NONE [195.UNKNOWN ESS9.OTHER(Specify): Aeo-'"re- 0'"/?-- 445& <br /> OVERFILL PREVENTION ❑ 1.AUDIBLE 8c VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE <br /> .W4.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 B 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR 263 a 3 458. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464& <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99-OTHER(Specify): 464c. <br /> PIPING/1'URBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644. <br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464e,. <br /> f. <br /> VENT SECONDARY CONTAINMENT [11.STEEL ❑ 4.FIBERGLASS [110.RIGID PLASTIC [190.NONE [199.OTHER(Specify): 4(Af1. <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46 <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464111 <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464,. <br /> RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4 j: <br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS [110.RIGID PLASTIC ❑ 90.NONE [199.OTHER(Specify): 464ki. <br /> FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451s c <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ❑ 1.SINGLE WALL _ ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469& <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC [199.OTHER(Specify) 446699cc. <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 449 <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 ig full om liance with legal requirements. <br /> APPLICANT SIGNATURE DATE no <br /> APPLICANT NAME(print) --�! �! 471. APPLICANT TITLE �'8 er u tS o 77 <br /> UPCF UST-13 Rev.(12/2007)-1/2 / www.unidocs.org <br />