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UNIFIED PROGRAM CONSOLIDATED FORM c UNDERGROUND STORAGE TANK 3(4 I I lIP lirOPERATING 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 1,11,111,IV,and IX below) 430 ❑ I.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE PT.-UST REMOVAL DATE UST PERMANENTLY CLOSED: 430' 1 DATE EXISTING UST DISCOVERED: / 430b FACILITY ID N(Agency Use Only) I. FACILITY INFORMATION I BUSINESS NAM (Same as FACILITY NAME or DBA-Doing siness As) 3 1,-'c V`1 P. s t ; le BUSS ITF/ADgIjESS 13 C 109 /l��L (�, n+h ' Las II.TANK DESCRIPTION TANK ID k 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 &I-A STAND-ALONE TANK El2.ONE M A COMPARTMENTED UNIT. Comlae oz me for aech comanmem in da unit. D T U T SYSTEM INSTALLED 435 TAN CAP CITY MOGFiL16NS 436 NUMBER OF COMP RTMENTS IN THE UNIT 432 III.TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ ].,AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includa Umd Oil) ❑ S.EMERGENCY GENERATOR FUEL]HSC 125291,5(,)] ❑ 6.OTHER GENERATOR FUEL IS5.UNKNOWN ❑ 99,OTHER (Specify): 4394 CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED Cl 3.DIESEL ❑ 5 JET FUEL � Ib.PREMIUM UNLEADED 440 ❑ S.PETROLEUM BLEND FUEL OTHER PETROLEUM Sem❑ 6.AVIAT ON GAS 44a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4101, IV. TANK CONSTRUCTION TYPE OF TANK .SINGLE WALL 02.DOUBLE WALL 095.UNKNOWN 443 PRIMARY CONTAINMENT 2TT.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99,OTHER (Specify): 444. SECONDARY CONTAINMENT ❑ I.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 M"!50,NONE 95.UNKNOWN ❑99.OTHERS eci 445. OVERFILL RREVENTION L3 I.AUDIBLE&VISUAL ALARMS 2.BALLFLOAT 7.FILL TUBE SHUT-OFF VALVE 452. J�.l C1 i'� C34.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED 02.DOUBLE-WALLED .OTHER idomd 469 SYSTEM TYPE ❑ 1,PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION r23 CCR 13636(1)(3)1 451 PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. SECONDARY CONTAINMENT ❑ L STEEL El 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10,RIGID PLASTIC 4641, ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specifyp 464c PIPINGrFURBINE CONTAINMENT SUMP TYPE FI 1.SINGLE WALL ❑ 2,DOUBLEWALL ❑ 90.NONE 4Md VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT Er I.STEEL D 4.FIBERGLASS D 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641, 4!,191 VENT SECONDARY CONTAINMENT El I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC .NONE ❑ 99.OTHER(Spnny) 4641' Mf1 VR PRIMARY CONTAINMENT LSTEEL O.FIBERGLASS ❑ 10.RIGID PLASTIC [aY90.NONE ❑ 99.OTHER(Specify) 464, 4w I VR SECONDARY CONTAINMENT ❑ I.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90,NONE ❑ 99.OTHER(Specify) 4NI 4641,1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2,DOUBLE WALL 90.NONE 4Wi, RISER PRIMARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC BrIN.NONE U 99.OTHER(Spaify) 464' 4641 RISER SECONDARY CONTAINMENT L STEEL El 4.FIBERGLASS C1 10.RIGID PLASTIC 0.NONE 0 99.OTHER(Spicily) 464k AkI FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET 3.STRIKER PLATFIBOTTOM PROTECTOR Cl 4.CONTAINMENT SUMP 431.., VII-UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS .NONE 4649 CONSTRUCTION MATERIAL ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Speci 469b< VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION ty C< 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 in full compliance with legal requirements. 470. APPLICANT SIGNATURE DATE Z Z3 APPLICANT NAME(print) 1! I 471, APPLICANT TITLE •�1,5 422. UPCF UST-B-1/2 Rev.(12/2007)