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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 this section and Sections 1,It,111,IV,and IX below) 430 [-11.NEW PERMIT E33.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: ...a I DATE EXISTING UST DISCOVERED 439b I. FACILITY INFORMATION FACILITY ID d(Agency Use Oldy) I BUSINES NAME(SameN FACILITY NAME or DBA-Doing Business As) 3 L BUSINESS SIT S Im CITY T,��za l04 11 ( ti ✓- II.TANK DESCRIPTION TANK ID N 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 ❑1.A STAND-ALONE TANK /1 iuJ f-1 r E]2.ONE IN A COMPARTMENTED UMT. /-r / Com le mepneformcbcompsnmtinNe=t DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLS 436 NUMBER OF COMPARTMENTS IN THE UNIT 433 -v 7i � a•UG C-IIonS Ill.TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ I,AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(mdW.Used 0i0 ❑ 5.EMERGENCY GENERATOR FUEL[HSC g252e1.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439. CONTENTS PETROLEUM: M la.REGULAR UNLEADED ❑ I..MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 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 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 512.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL ®.3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL,INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER S ci a44a SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER 8 eci : 445. OVERFILLPREVENTION [I 1.AUDIBLE&VISUAL ALARMS 2.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 ❑2.DOUBLE-WALLED ❑99.OTHER 4W SYSTEM TYPE LPRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§e30aX3)1 458 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN O 99,OTHER(Specify): 464. SECONDARY CONTAINMENT O 1.STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGfFURBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4Md VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC El 90.NONE ff 99.OTHER(Specify) 4644 6441 VENT SECONDARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC EI W.NONE W.OTHER(Specify) 464f VR PRIMARY CONTAINMENT 0 L STEEL 0 4.FIBERGLASS 10,RIGID PLASTIC [190.NONE 0 99.OTHER(SpAT9xify) 4646 41 VR SECONDARY CONTAINMENT 0 I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 464h 64h1 VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL 2.DOUBLE WALL 0 90.NONE 464i. RISER PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ W.OTHER(Spaify) 4641 4H'I RISER SECONDARY CONTAINMENT ❑ I STEEL ❑ 4.FIBERGLASS ❑ IO.RIGIDPLASTIC 90,NONE 0 99.OTHER(Spsify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET ❑ 3.STRIKER PLATEBOTTOM PROTECTOR LA 4,CONTAINMENT SUMP 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE [21 L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469. CONSTRUCTION MATERIAL ❑ 1.STEEL C.4.FIBERGLASS ❑ 1 O.RIGID PLASTIC ❑ 99 OTHER(Specify) 4696-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED C URRFNT ❑ 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 hereip is(r_.ue,accurate, and in full compliance with legal requirements. APPLICANT SIGNATURE DATE Of n / 470 APPLICANT NAME(print) E 411APPLICANT TITLE f 4� 472' i UPCF UST-B-12 Rev.(12/2007)