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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only s section and Sections I,II,III,IV,and IX below) 4w tau 1.NEW PERMIT ❑ 3_RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430. DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as FACII.ITY NAME or DBA-Doing Business As) 3 V BUSINESS SITE ADDRESS 103 CITY too .� H.TANK DESCRIPTION TANK ID# i 43'- TANK MANUFACTURER a33 TANK CONFIGURATION: THIS TANK IS a3a r � � 1.A STAND-ALONT TANK (� W 33 ❑2.ONE IN A COMPARTMENTED UNIT. Caniplcw u c for tach=iparmmt in the unit DATE UST SYSTEM INSTALLED 435 TANK CAPACITY.IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT , 437 III.TANK USE AND CONTENTS TANK USE ❑ la MOTOR VEHICLE FUELING ❑ ib.MARINA FUELING ❑ Ic.AVIATION FUELING day ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Imhnles Uscd Oil) ❑ 5.EMERGENCY GENERATORFUEL[RSC§25281 S(c)) .U ❑ 6.OTHER GENERATOR FUEL ❑ 95NKNOWN 99.OTHER (Specify): `-'4+_6-- .\j.it,. 439. CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3_DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION%kS ❑ 8.PETROLEUM BLEND FUEL E'9.OTHER PETROLEUM (Specify): I/' 4V 440' NON-PETROLEUM:❑ 7.USED OIL ❑ 10_ETHANOL ❑ 1 i_OTHERNON-PETROLEUM(S ): 4406 IV. TANK CONSTRUCTION TYPE OF TANK 43 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT 0. 1.STEEL ❑ 3_FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S ): 445a OVERFILL PREVENTION ❑ L AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. a 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONMUCTJON ❑1.SINGLE-WALLED [12.DOUBLE-WALLED ❑99 OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(.83)) 458 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ I_STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10_RIGID PLASTIC 464b ❑ 90_NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGMJRBINE 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 ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99-OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ 1_STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 4641 VR PRIMARY CONTAINMENT ❑ I_STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464¢1 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL ❑ 2-DOUBLE WALL ❑ 90_NONE 4641. RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464) 464-1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90_NONE ❑ 99 OTHER(Specify) 464k 4641 FILL COMPONENTS INSTALLED ❑ i.SPILL BUCKET ❑ 3.STRTKER PLATFiBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2_DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90_NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IR. 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 in fall compliance with legal requirements. 470. APPLICANT SIGNATURE ) DATE APPLICANT NAME(print) 471- APPLICANT TITLE 472. UPCF UST-B-1/2 Rev.(1212007)