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� � l UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form cr UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,IN,IV,and IX below) 430 ❑ I.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.=OVAL INFORMATION El 6.TEMPORARY UST CLOSURE [17.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430° DATE EXISTING UST DISCOVERED: 4J% L FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 F/`4n rS �e2 BUSINEs ADDRESS nl{mac od. lu3 QTY nC C� l04 II.TANK DESCRIPTION TANK ED#er.AC)L" p�y / 432 TANK MANUFACTURER 433 T CONFIGURATION: THIS TANK IS 434 IT l.�OCL�CJ (O 1.A STAND-ALONE TANK Unknown c (f/I kri Owrt ❑2.ONE IN A COMPARTMENTED UNIT. corrnlete we fore mm tin ttruoie ",DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS a36. NUMBER OF.COMPARTMENTS IN.THE_UM'f'. . . _ _._43 i _ M.TANK USE AND CONTENTS TANK USEIa.MOTOR VEHICLE FUELING ❑ It.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(mcmda W° 00) ❑ 5.EMERGENCY GENERATOR FUEL[HSC 6252s1.5(c)l ❑ 6.OTHER G OR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439e CONTENTS PETROLEUM: a is REGULAR UNLEADED ❑ 1c.MIDGRADE UNLEADED ❑ lb.PREMJUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.IET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S wi : 449° NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUMS i : a4ot IV. TANK CONSTRUCTION TYPE OF TANK 1XI.SINGLEWALL ❑ 2.DOUBLEWALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): a4a SECONDARY CONTAINMENT1.STEEL ❑3.FIBERGLASS [16.EXTERIOR MEMBRANE LINER [17.JACKETED 445 90.NONE [195.UNKNOWN ❑99.OTHER(S eri : 4454 OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE //ONE 452" ❑ 4.TANK MEETS REQUIREMENT'S FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION .SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTBER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY3.CONVENTIONAL SUCTION [14.SAFE SUCTION[23 CCR 4263 aA3)I 458 PRIMARY CONTAINMENT 1.STEEL LJ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): bb4a SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC a6ts 0.NONE ❑ 95.UNKNOWN ❑ 99.01T ER(Specify): 4640 PIPING,TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ].STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4" 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC 90.NONE ❑ 99.OTHER(Specify) 464f 464(1 VR PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS 10.RIGIDPLASTIC T&90.NONE 99.OTHER(Specify) 464, 464'I VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464h 46M1 VENT PIPING TRANSITION SUMP TYPE EI 1.SINGLE WALL ❑ 2.DOUBLE WALL 19 90.NONE 4641. RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ZN90.NONE ❑ 99.OTHER(Specify) i RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464k 464kl FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATEMOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP aAJ 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS or 90.NONE 469° CONSTRUCTION MATERb1L ❑ L 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 N U Al 05 a48. 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 legall requirements. APPLICANT SIGNATURE /+L DATE //Z 2/,1_7 aio. APPLICANT NAME(print) f�'-- 411' APPLICANT TITLE /lU �{ Jt�it-J C-'6•'lTY`4 G]ta/� UPCF UST-B-1/2 Rev.(12/2007)