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D � lb/IU�IZ 5 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) 1 TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,IL III,IV,and IX below) 430 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ &UST REMOVAL DATE UST PERMANENTLY CLOSED: 4m' DATE EXISTING UST DISCOVERED: 4306 L FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as FACILITY NAME mDBA-Doing Business As) 3 BUSI)Fj SI]'EADDREStW/ ^M t14__)1 (� 103 CITY n OBS la 1 4 C7 IL TANK DESCRIPTION TANK ID It ivyy/,D 432 TANK MANUFACTURER 433 TANKCONmGURA710N: TrnSTANK IS 4M (_(Ce ^❑wL A STAND-ALONE TANK 3-4rL.ONE W A COMPARTMENTED UNIT. C eta ane for arL M�wt DATE U YSTF INS^A1 1i D 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 4n �p / L IJO III.TANK USE AND CONTENTS TANK USEa.MOTOR VEHICLE FUELING [I lb.MARINA FUELING ❑ Ic.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Indu uxd mi) ❑ 5.EMERGENCY GENERATOR FUEL Bea:425261.5(c)1 ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439. CONTENTS PETROLEUM: ❑ la REGULAR UNLEADED ❑ lc MIDCRADE UNLEADED ❑ lb.PREMIUM-UNLEADED " DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM 440a NON-PETROLEUM:❑ 7.USED OIL ❑ METHANOL 11.OTHER NON-PETROLEUMS 4406 IV. TANK CONSTRUCTION TYPE OF TANK 1.SINGLE WALL .DOUBLE WALL 95.UNKNOWN 4G PRIMARY CONTAINMENT ❑ I.STEEL '�3.FIBERGLASS ❑ b.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL �.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 [190.NONE 95.UNKNOWN ❑99.OTHERS 445. OVERFILL PREVENTION I. AUDIBLE&VISUAL ALARMS .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 01.SINGLE-WALLED M*.DOUBLE-WALLED El99.OTHER 460 SYSTEM TYPE iirL PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR I2636(aX3)1 458 PRIMARY CONTAINMENT ❑ 1.STEEL [ta 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Spedly): 464a SECONDARY CONTAINMENT ❑ 1.STEEL lj3'4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 46M ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): a6ac PIPING(IURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL W.DOUBLE WALL ❑ 90.NONE a6ad VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL '4.FIBERGLASS 0 10.RIGID PLASTIC El 90.NONE 0 99.OTHER(Specify) 464e 469e1 VENT SECONDARY CONTAINMENT t.STEEL QI 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464f 64Fl VR PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 0 10.R1GBD PLASTIC 90.NONE ❑ 99.OTHER(Specify) 0/.J 6 49 VR SECONDARY CONTAINMENT ❑ 1.STEEL. 4.F111ERGLASS 0 HL RIGIDPLASTIC ❑90.NONE ❑ 99.OTHER(SpeciTy) O ! = VENT PIPING TRANSITION SUMP TYPE ❑ t.SINGLE WALL M.DOUBLE WALL 90.NONE 2 4641. RISER PRIMARY CONTAINMENT 1.STEEL C1 4.FIBERGLASS 0 10.RIGID PLASTIC U 90.NONE ❑ 99.OTHER(Specify) 4644 411 RISER SECONDARY CONTAINMENT ❑ 1.STEEL W4.FIBERGLASS D 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 464k 46 FILL COMPONENTS INSTALLED el.SPILLBUCKET ja 3.STRIKER PLATFJBOTfOM PROTECTOR SF4.CONTAINMENT SUMP 451. VIL UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469. CONSTRUCTION MATERIAL ❑ 1.STEEL IF4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT M6.ISOLATION LY. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is Frue,accurate, and in fall com liance with legal rc uircmenM APPLICANT lr�%) 42,L.- DATE Z3 ' ' 479. API'LIC AME r) 471 APPLICANT TITLE D j 472. t( UPCF UST-11-1/2 Itn.,(fybp7)