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UNIFIED PROGRAM CONSOLIDATED FORM` S UNDERGROUND STORAGE TANKDr 0VeEE OPERATING PERMIT APPLICATION - TANK INFORMA TYPE OF ACTION (Check one item only. For,n UST permanent closure or removal, complete only this Section and Sections I, B, III, IR V- -I IX below C 430 1. NEW PERMIT : 3. RENEWAL PERMIT ❑ S. CHANGE OF INFO mPIIItYN u ❑ 6. TEMPORARY UST CLOSURE LJ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: °30i I DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION ENVIRONMENTAL HEALTF FACILITY ID # (Agency Use only) - - D P RT E T t BUSINESS NAME (Same as FACILITY NAME or DBA-DIing Business As) UN Vr45lbi 2356 T k 05 )-0'g 11 len y� BUSINESS SITE AD r tR�103 N��rt� �.Ara� CITY io4 tGpt 1.,3 tl l��rll� H. TANK DESCRIPTION TANK ID # 432 TANK MANUFACTURER 433 TANK CONFIGURATION: TFIIS TANK IS 434 I� �j J *2, C6NS'Pt lim M tAT- s©L\J 1101-a 1. A STAND-ALONE TANK � 2. ONE M A COMPARTMENTED t1NT. Com kte one pap for earbw tin me wdt. DATE UST SYS INSTALLED 435 TANK jY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 l.9pqCI M. TANK USE AND CONTENTS TANK USE N la MOTOR VEHICLE FUELING ❑ Ib. MARINA FUELING ❑ Ic. AVIATION FUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE(I.duda Used Oil ❑ 5. EMERGENCY GENERATOR FUEL IHSC¢25291.5(c)I ❑ 6.OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la REGULAR UNLEADED ❑ Ic. MIDGRADE UNLEADED 10 lb. PREMIUM UNLEADED 440 ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ S. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (S ): "0. NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ❑ 11. OTHER NON -PETROLEUM (Specify): 46ob IV. TANK CONSTRUCTION TYPE OF TANK El 1. SINGLE WALL 02. DOUBLE WALL 095. UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1. STEEL 0 3. FIBERGLASS ❑ 6. INTERNAL BLADDER ab4 ❑ 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99.OTHER (Spaify): 444a SECONDARY CONTAINMENT ❑ 1. STEEL 0 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED M5 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER 5 i ): a5a OVERFILL PREVENTION 0 1. AUDIBLE & VISUAL ALARMS ❑ 2. BALL FLOAT 0 3. FILL TUBE SHUT-OFF VALVE 452. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/ WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1. SINGLE -WALLED 02. DOUBLE -WALLED ❑99.OTHER "a SYSTEM TYPE 0 1. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION W CCR 52636(a)(3)] 459 PRIMARY CONTAINMENT ❑ L STEEL ■ 4. FIBERGLASS ❑ S. FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER(Specify): 466a SECONDARY CONTAINMENT ❑ 1. STEEL 0 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC a6w ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ I. SINGLE WALL 0 2. DOUBLE WALL ❑ 90. NONE 464d VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1. STEEL 0 4. FIBERGLASS 0 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464e 464 1 VENT SECONDARY CONTAINMENT 0 1. STEEL 0 4. FIBERGLASS 10. RIGID PLASTIC ❑ 90. NONE ❑ 99.OTHER (Specify) a64f 466n VR PRIMARY CONTAINMENT 1. STEEL i 4. FIBERGLASS 0 10. RIGID PLASTIC 0 90. NONE 99. OTHER (Specify) 664g 664 1 VR SECONDARY CONTAINMENT ❑ I. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC 090. NONE ❑ 99. OTHER (Specify) 466h 46an1 VEIN PIPING TRANSITION SUMP TYPE ❑ L SINGLE WALL 0 2. DOUBLE WALL Q 90. NONE 464i. RISER PRIMARY CONTAINMENT 1. STEEL 0 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) a64j 466' 1 RISER SECONDARY CONTAOQMEM❑ I. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC 10 90. NONE 099. OTHER (Specify) 4664 464k1 FILL COMPONENTS INSTALLED 0 L SPILL BUCKET ❑ 3. STRIKER PLATE/BOTTOM PROTECTOR N 4. CONTAINMENT SUMP 451a, VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ❑ I. SINGLE WALL 0 2, DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 469. CONSTRUCTION MATERIAL ❑ 1. STEEL 0 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 46%, VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION I ❑ 2. SACRIFICIAL ANODES) ❑ 4. IMPRESSED CURRENT 0 6. ISOLATION a48. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this T system is compatible with the ha2ardoas substance stored and that the information provided herein is true, accurate, and in full com lia with !!gal requirements. APPLICANT SIGNATURE DATE 420 APPLICANT NAME (print 021 APPLICANT TITLE (� r N 4n. UPCF UST -B -1/2 Rev. (12/2007)