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i UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. Foran UST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) +30 ❑ 5.CHANGE OF INFORMATION ❑ I.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE Q 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4104 DATE EXISTING UST DISCOVERED: +lob FACILITY ID N(:lgencv Use Only) I. FACILITY INFORMATION BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) R BUSINES SITE ADDRESS 103 CITY h q5?/S TANK IDN A OIL, (0( D,�± TANK IL TANK DESCRIPTION MANUFACTURER +33 TANK CONFIGURATION: THIS TANK IS 434 L 3�Jo0� aD-ALONE TANK say ❑� I.ASTANACOMPARTME �n�ay�roa Tr GQ �2.ONEINACOMPARTMENTEDIIN'IT. DATE UST SYSTEM INSTAL LED 435Com "Sef9reach oam srtmnalnme.,1 TANK CAPACITY IN GALLONS 436 NUMBER OFCOMPART ENTS IN"THE UNIT +37 TANK USE St la.MOTOR VEHICLE FUELING [II.TANK USE AND CONTENTS ❑ Ib.MARINA FVELING Q 3.CHEMICAL PRODUCT STORAGE (j 4.HAZARDOUS WASTE(IndWea Usad Gill Q IC.AVIATION FUELING 439 Q 6.OTHER GENERATOR FUEL Q 95.UNKNOWN ❑ 5.EMERGENCY GENERATOR FUEL IIISC§'281.yc)I CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADEDQ 99.OTHER (Specify): 4394 19 3.DIESEL Q Ic.MIDGRADE UNLEADED Q Ib.PREMIUM UNLEADED 440 Q 5.JET FUEL Q b.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL Q 9.OTHER PETROLEUM g if); NON-PETROLEUM:❑ Z LSED OIL ❑ 10.ETHANOL 1 L HER NON-PETROLEUM IS i ): 449b IV. TANK CONSTRUCTION TYPE OF TANK ❑ ?.DOUBLE WALL Q95.UNKNOWN PRIMA RY CONTAINMENT 1.SINGLE WALL 44J I.FIBERGLASS ❑ b.INTERNAL BLADDER 4u ❑ 7.STEEL-INTERNAL LIVING ❑ 95.UNKNOWN ❑ 99.OTHER SECONDARY CONTAINMENT ❑ LSTEEL $I 3.FIBERGLASS (S r 4444 ❑ 90.NONE ❑ 6.EXTERIOR MEMBRANE LINER Q 7 JACKETED 445 OVERFILL PREVENTION ❑ 95.UNKNOWN Q 99.OTHER IS i ); 4454 I.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT +5� V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑I.SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER SYSTEM TYPE 1.PRESSURE '.GRAVITY 460 PRIMARY CONTAINMENT Q }.CONVENTIONAL SUCTION Q 4.SAFE SUCTION[23 CCR 426Jrya8J1 458 _NE 0 4.FIBERGLASS Q 8.FLEXIBLE ❑ W.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN Q 99.OT jS ecify): SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS E] ::g 8.FLEXIBLE 464a ❑ 90.NONE 1-195.UNKNOWN ❑ 10.RIGID PLASTIC 4641,PIPINGITURBINE CONTAINMENT SU MP TYPE DOUBLE WALL 4644❑ 99,OTHER(Specify): 46Jc ❑ I.SINGLE WALL B 2, ❑ 90.NONE VI.VENT,VAPOR RECOVERY(VR)AND RISER VENT PR /FILL PIPE PIPING CONSTRUCTION PRIMARY I, I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464e VENT SECONDARY CONTAINMENT Q I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4464f VR PRIMARY CONTAINMENT Q L STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC90.NONE 99.OTHER(Specify) 64n s VR SECONDARY CONTAINMENT L STEEL Q 4.FIBERGLASS 10.RIGID PLASTIC ".NONE464.1 VENT PIPING TRANSITION SUMP TYPE 99.OTHER(Specify) 4641 I.SINGLE WALL 2.DOUBLE WALL 90.NONE +64hI RISER PRIMARY CONTAINMENT [.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 4641, 90.NONE 99.OTHER(Specify) 464j RISER SECONDARY CONTAINMENT I.STEEL 4.FIBERGLASS 10,RIGID PLASTIC 90.NONE FILL COMPONENTS INSTALLED 99.OTHER(Specify) 464k I.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 491 kI VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE I.SINGLE WALL Q 2,ppUBLE WALL ❑ },NO DISPENSERS CONSTRUCTION MATERWL I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC Q NO 4694 ❑ 99.OTHER IS i ) 4646.. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION Q 2.SACRIFICIAL ANODE(S) $4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. LY. APPLICANT SIGNATURE CERTIFICATION: 1 certify at thl US stem is and in l c ce i[h I with the hazardous suhsuxe stored and that the Information provided herein is true,accurate, f al rere quir uireme nb. APPLICANT SIGNATURE DATE /- 2,j- /O 470. APPLICANT NAME(p t) 471, APPLICANT TI E 472. UPCF UST-B-1/2 -.. v.(12/2007)