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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UsT) TY YE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I IIIII IV,and DC below) 430 I.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ S.UST REMOVAL 1 DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION p J FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as FACII,TTY NAME or DBA-Doing Business As) 3 BUSINESS-SITE ADDRESS 103 CITY 104 .. - H.TANK DESCRIPTION TANK ID# it N432 TANK MANUFACTURER 433 TANK CONFIGURATION: THLS TANK is 434 1.A STAND-ALONE TANK / ' I ❑ 2-ONE IN A COMPARTMENTED UNIT. Qxnocic one pW for tach conVmmnent m the mut DATE UST SYSTEM INSTALLED 435 TANK CAPACITY.IN GALL NUMBER OF COMPARTMENTS IN THE UNIT 437 C�-J,L+I .'� III.TANK USE AND CONTENTS TANK USE ❑ l a.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ l c.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE{7,:cmde=Used Off) ❑ 5.EMERGENCY GENERATOR FUEL[ASC¢75281-5(c)] ❑ 6.OT HERR GENERATOR FUEL ❑ 95.UNKNOWN ja 99,OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.A TION GAS ❑ 8.PETROLEUM BLEND FUEL M9.OTHER PETROLEUM ( i ): 440, NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(S ' IV. TANK CONSTRUCTION TYPE OF TANK I.SINGLE WALL ❑ 2-DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT a L STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER ( ): 444. SECONDARY CONTADIMENT ❑ 1.STEEL [13.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7-JACKETED 445 ❑ 90.NONE El 95.UNKNOWN ❑99.OTHER(S _ 445. OVERFILL PREVENTION 831.AUDIBLE g VISUAL ALARMS ❑ 2-BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452 ja 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED [12-DOUBLE-WALLED El99.OTHER 460 SYSTEM TYPE ❑ L PRESSURE ❑ 2-GRAVITY ❑ 3-CONVENTIONAL SUCTION ❑ 4_SAFE SUCTION[23 CCR¢266#3)] ass PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ I0.RIGIDPLASTIC 44 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99-OTHER(Specify): 4Ma SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99-OTHER(Specify): 454` PIPINGrrURBiNE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2_DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4-FIBERGLASS ❑ ]0.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL [14.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99-OTHER(Specify) 464f 464(1 VR PRIMARY CONTAINMENT L STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(specify) 464g VR SECONDARY CONTAINMENT ❑ I-STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 44L RISER PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 441 1 RISER SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 46ak1 FILL COMPONENTS INSTALLED ❑ I.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR 4-CONTAINMENT SUMP 451a-c VII.UNDER DISPENSER CONTAINMENT(UDQ CONSTRUCTION TYPE ❑ 1.SINGLE WAIL. ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL. ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 99.OTHER(Specify) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2-SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION:I certify that this UST system is compatible with the hazardous substance stored and that the Information provided herein is true,accurate, and m full compliance with legal requirements. 470. APPLICANT SIGNATURE /j DATE -7 l t ( ]1 APPLICANT NAME(print) 471 a7z. APPLICANT TITLE S UPCF UST-9-112 Rev.(12/2007)