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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION -TANK INFORMATION (O TYPE OF ACTION (Check one item only. For,., UST Permanent closure or removal, complete only this section and Sections I, 11, III, IV, and IX below) 430 L NEW PERMIT 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 6. TEMPORARY UST CLOSURE Ll 7. UST PERMANENT CLOSURE ON SITE ❑ R. UST R V DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST D15COVE 3 b I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) 1 ni BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) , I _ -%R tee vrl �r-1pSti C}If�V1 T� 235D 06 AD910 B2INES�SJS�IT,E AD REm,M'�s� (..Q,IJ� 103 (�, CITY �p,� It (l/,wl,y fes✓ lw IL TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TTAANKCONFIGURATION: THISTANKIS 434 rk1. ASTAND-ALONE TANK . I'.� E]2. ONE IN A COMPARTMENTED UNIT. W ITO/ t, Com tete one pw for each wm anment in the wit. DATE USTS 435 GALLONS 436 TANK CAAPPAA IITTYYI NUMBER OF COMP RTMENTS IN THE UNIT 037 %INSTALLED III. TANK USE AND CONTENTS III. TANK USE R Ia. MOTOR VEHICLE FUELING ❑ Ib. MARINA FUELING ❑ le. AVIATION FUELING 639 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE(Indadc Used 0i0 ❑ 5. EMERGENCY GENERATOR FUEL [HSC §252815(c)] ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439a CONTENTS PETROLEUM: X la. REGULAR UNLEADED ❑ Ic. MIDGRADE UNLEADED ❑ Ib. PREMIUM UNLEADED 446 ❑ 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 -PETROLEUMS eci ): 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ I. SINGLE WALL ■ 2. DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT ❑ L STEEL E 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 ❑ 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 444. SECONDARY CONTAINMENT ❑ L STEEL ■ 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 445. OVERFILL PREVENTION M 1. AUDIBLE & VISUAL ALARMS [12. 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 ❑ I. SINGLE -WALLED a 2. DOUBLE -WALLED ❑ 99. OTHER 460 SYSTEM TYPE E 1. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION 123 CCR 12636(a)(3)] 458 PRIMARY CONTAINMENT ❑ L STEEL ® 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER(Specify): 4Ma SECONDARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 4646 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1. SINGLE WALL W 2. DOUBLE WALL ❑ 90. NONE 464d VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ LSTEEL ■ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER(Spwify) 464e 464c1 VENT SECONDARY CONTAINMENT ❑ L STEEL N 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464f 4640 VR PRIMARY CONTAINMENT ❑ I. STEEL M 4. FIBERGLASS EI 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 4645 464 1 VR SECONDARY CONTAINMENT ❑ I. STEEL 0 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Speeify) 4Mh 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ I. SINGLE WALL 2. DOUBLE WALL ❑ 90. NONE 4Mi, RISER PRIMARY CONTAINMENT 0 L STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 4641 4641 RISER SECONDARY CONTAINMENT ❑ L STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC E 90. NONE ❑ 99. OTHER (Specify) 464k 464k1 FILL COMPONENTS INSTALLED 0 I. SPILL BUCKET ❑ 3. STRIKER PLATE/BOTTOM PROTECTOR If 4. CONTAINMENT SUMP 451 a -c VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ❑ I. SINGLE WALL a 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 469a CONSTRUCTION MATERIAL ❑ E STEEL F 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 4696-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTI ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT 6. ISOLATION 448, IX. APPLICANT SIGNATURE CERTIFICATION: I certify that t 's UST system is compatible with the han4rdous substance stored and that the information provided herein is true, accurate, and in full com 'ante with legl requirements. APPLICANT SIGNATURE DATEbbe 470 APPLICANT NAME (print n ^ n 401 APPLICANT TITLE / 472. t 1 / 'V UPCF UST -B -1/2 Rev. (122007)