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q ~ UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK JUN 0 3 2015 OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) 42 1 TYPE OF ACTION (Check one item only. For ST permanent closure or removal,complete only this section and Sections I,II, ❑ 1.NEW PERMIT 3.RENEWAL PERMIT ❑ 5.CHANGE ns INFO 0 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE t�pD9 DT'§#Ca1T DATE UST PERMANENTLY CLOSED: $.UST REMOVAL �� Z - 43oa DATEEXISTING UST DISCOVERED: QN a30b FACILITY ID#(Agenry Use Only) L FACILITY INFORMATION 7V5 B'> S1�iES,S-IsiA•ME(Same W FACILITY NAME or DBA-Doing Business As) qp 3 BUS FSS ADD ot VM ` ` J` l03 CIn]yt� n cp,. 104 �( B" 6 1 II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 ' -TANK1.A STAND-ALONE TANKS TANK 7S �� 434 O V ❑2.ONE IN A COMPARTMENTED UNU. DATE UST SYSTV ST LED 435 TANK CAPAC YIN GALj�NS 476 Com leoeaue aefor each mm.mnmUe tlieuNc IT NUMBER OF COMPAR N W THE UNIT 437 f%i TANK USE ❑ ]a.MOTOR VEHICLE FUELING III-TANK USE AND CONTENTS Q 3.CHEMICAL PRODUCT STORAGE Q 16 MARINA FUELING Q Ic.AVIATIONFUELING 439 Q 4.HAZARDOUS WASTE N-]W-Used Oil) Q 5.EMERGENCY GENERATOR FUEL pSSC§25281.5(e)] Q 6.OTHER GENERATOR FUEL �5.UNKNOWN ❑ 99EM R G (Sped ); 4394 CONTENTS PETROLEUM: ❑ Ia REGULAR UNLE ED ❑ ]c.MIDGRADE UNLEADED Q ib.PREMIUMUNLEADED 444 Q 3.DIESEL Q 5.JET FUEL, ❑ 6.A ON GAS Q S,PETROLEUM BLEND FUEL. Q 9.OTEER PETROLEUM ($ NON-PETROLEUM:❑ 7.USED OIL a4oa ❑ 10,E1OL I1.OTHER NON-PETROLEUM 5 eci 449b TV. TANK CONSTRUCTION TYPE OF TANK Q 1.SINGLE WALL Q 2.DOUBLE WALL95.UNKNOWN PRIMARY CONTAINMENT Q 1.STEEL 3.FIBERGLASS Ogg INTERNAL BLADDER 4a7 Q 7.STEEL+INTERNAL LINING95.UNKNOWN El 99, ER (S ea ; 4 SECONDARY CONTAINhtENf ❑ 1,$TEFL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE EL LINER ❑ 7.SACKETED "aas ❑ 90.NONE 95.UNKNOWN Q 99,OTHER(S eci ): OVERFILL PREVENTION ❑ 1.AUDIBLE St VISUAL ALARMS Q 2.BALL£COAT ❑ 3.FILL Tt1BE S51 1 OFF Y4asa ALVE 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT 452. V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION EILSINGLE-WALLED Q2.1)OUBLE-WALLED 99.OTHER SYSTEM TYPE ❑ L PRESSURE Q L.GRAVITY Q 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(2O cat........... 458 PRD y CONTAINMENT Li 1.STEEL Q 4.FIBERGLASS Q S.FLEXIBLE Q 10.RIGID PLASTIC 464 Q 90.NONE Q 95.UNKNOWN ❑ 99.OTHERS eeify): qg,a SECONDARY CONTAINMENT L STEEI. ❑ 4.FIBERGLASS Q S.F LUES Q 10.RIGID PLASTIC 464b Q 90.NONE Q 95,UNKNOWN ❑ 99.OTHER(S eci ): 464c PIPING/fURBINE CONTAAIMENT SUMP TYPE Q 1.SINGLE WALL Q 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPO RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEHL ❑ 4.FffiERGLASS 10,RIGID PLASTIC 141-,90-NONE Q 99.01HER(Specify) 464e VENT SECONDARY CONTAMLv1ENT Q 1,STEEL Q 4.FIBERGLAS$ ]0.RIGID PLASTIC 90.NONE ❑ 99,p'['IffiR(Specify) 4441 VR PRIMARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASSLJ 10.RIGID PLASTIC �L 90.NONE 0 99.6T-HER(Specify) 4648 VR SECONDARY CONTAINMENT ❑ i.STEEL 4.FffiERGLA$S Q 10.RIGID PLASTIC �,90.NONE 99,OTHER(Specify) a6ah VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 464hl RISER PRIMARY CONTAINMENT 1.STEEL U 4.F03ERGLASS Q 10.R[GID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464,' RISER SECONAARY CONTAINMENT ❑ 1. U 4.FffiERGLASS Q 10.RIGID PLASTIC A 90.NONE ❑ 99,OTHER(Specify) 4Uk FILL COMPONENTS INSTALLED 1.SPILL BUCKET ❑ 3,STRDCER PLATEBOTTOM PROTECTOR 4.CONTAINMENT SUMP 4451�lVII.UNDER DISPENSER CONTAINMENT(UDC)CONSTRUCTION TYPE 1.SINGLE WALL Q 2.DOUBLE WALL Q 3,NO DISPENSERS Q 90.NONE CONSTRUCTION MATERIAL H 1,STEEL ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 99.OTHER $ eci )VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT O 6.ISOLATION LY APPLICANT SIGNATURE CERTIFICATION:kern- hat'E�s U , ystem is compatible with the hazardous substance stored and that the information provided herein is true,accurate, au4hn full com lian6e ith I al re uirements. APPLICANT,yl ATURE ` DATE �y .TSl 430. APE ✓-�Np (-p✓t) a 631 APPLICANT 432. ,>w�•a..��'`moo UPCF UST-B-1/2 Rev.(1212007)