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11 �r UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) F.T.-Y :.ACTION (Check one item only. For an UST peamanent closure or removal,complete only this section and Sections I,II,I1I,IV,and IX below) 430 NEW PERMIT ❑ 3_RENEWAL PERMIT ❑ 5.(MANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED_ 430a DATE EXISTING UST DISCOVERED: a30b I. FACILITY INFORMATION FACILITY ID 11(Agency Use Only) _ j _ 1 BU S NAME(Setae as FACILITY NAME or DBA-Doing Business As) 3 ,03 1 CITY m04 H.TANK DESCRIPTION TANK ID#1 �(432 TANK MANUFACTURER 433 TANK CONFIGURATION=TRIS TANK IS 434 t 1.ASTAND-ALONE TANK ❑2.ONE IN A COMPARTMENTED UNIT- onc for tach conwarmam m the omt. D UST_aYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 '2.0 III.TANK USE AND CONTENTS TAMC USE ❑ Ia.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ la AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4_HAZARDOUS WASTE(Iaclades Used Off) ❑ 5.EMERGENCY GENERATOR FUEL[MC 125281 S(c)l ❑ 6-OTHER GENERATOR FUEL ❑ 95.UNKNOWN Ja 99.OTHER(Specify): - Vl,", 439a CONTENTS PETROLEUM: ❑ I&REGULAR UNLEADED ❑ Ic.MIDGR4DE UNLEADED ❑ lb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5_JET FUEL ❑ 6_ TION GAS ❑ 8.PETROLEUM BLEND FUEL CST 9.OTHER PETROLEUM Y•\ '- 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ I L OTHER NON-PETROLEUM( 4406 IV. TANK CONSTRUCTION TYPE OF TANK 41rl.SINGLE WALL ❑ 2-DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT J.I-STEEL ❑ 3.FIBERGLASS ❑ 6_INTERNAL BLADDER 444 7_STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑99.OTHER ( k 444a SECONDARY CONTAINMENT ❑ 1_STEEL ❑3.FIBERGLASS ❑ 6_EXTERIOR MEMBRANE LINER [17.JACKETED 443 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER( 445a OVERFILL PREVENTION ❑ 1_AUDIBLE&VISUAL ALARMS Z BALI.FLOAT ❑ 3_FILL.TUBE SHUT-OFF VALVE 452- J4 52I4 4.TANK MITTS REQUMEMENTS FOR E}LFAIP'TION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE WALLED ❑L DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4_SAFE SUCTION p3 CCR§2636(ax3)1 458 PRIMARY CONTAINMENT ❑ 1_STEEL ❑4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99-OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL ❑4_FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify)_ 4640 PIPINGIIURBWE 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 ❑ I_STPEL ❑4.FIBERGLASS Ll 10.RIGIDPLASTIC 0 90.NONE ❑ 99.OTIIER(Specify) 4W 464el VITT SECONDARY CONTAINMENT ❑ I-STEEL 4.FIBERGLASS 10.RIGIDPLASTIC 90.NONE 0 99-OTHER(Specify) 464f 464fl VR PRIMARY CONTAINMENT 1.STEEL 4_FIBERGLASS 10.RIGID PLASTIC 0 9o.NONE El 99.OTHER(Specify) 44648 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑4_FIBERGLASS ❑ 10_RIGID PLASTIC ❑ 90.NONE ❑".OTHER(Specff) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 0 2_DOUBLE WALL 90.NONE 464L RISER PRIMARY CONTAINMENT 1_STEEL U 4_FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 464il RISER SECONDARY CONTAINMENT ❑ 1_STEEL ❑ 4.FIBERGLASS ❑ 10_RIGID PLASTIC ❑ 90_NONE ❑ ".OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3_STRIKER PLATE/BOTTOM PROTECTOR ❑ 4_CONTAINMENT SUMP 4512-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ I_SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISP04SERS ❑ 90_NONE 469a CONSTRUCTIONMATERIAL ❑ 1_STEEL ❑ 4.FIBERGLASS ❑ 10_RIGIDPLASTIC ❑ 99.OTHER(Specify) 469b-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2-SACRIFICIAL ANODE(S) ❑ 4.IIM[PRISSED 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, aad in fnII compliance with lezal requirements, 470. APPLICANT SIGNATURE /j DATE APPLICANT NAME(print) an APPLICANT TITLE 472- IS :4 Cie UPCF UST-B-1/2 Rev•(12aN7)