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iqEGEIV UNIFIED PROGRAM CONSOLIDATED FORM 1� UNDERGROUND STORAGE TANK JUN 0 3 2015 `$1 OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. For ST permanent closure or removal,complete only this section and Sections I,II, ° ❑ 1.NEW PERMIT I RENEWAL PERMIT ❑ 5.CHANCE OF INFO x911 nC09OTAAChIT 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE S.UST REMOVAL.e Q DATE UST PERMANENTLY CLOSED: \c( z- - 4300 DATE EXISTING UST DISCOVERED: v 4306 L FACILITY INFORMATION FACILITY ID#(Agency Use Only) 5"?g3 1 1 J _ I I I I _ I I I1 $HSIk�F1.fiS.S-N{tId[E(Same as FACILITY NAME or DBA-Doing Business As) ••�^pp 3 BUSIjAI"dS.SE I03 i.-pr l04 �$ I IL TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK ONFIGURATGN: THIS TANK IS t 434 OV, . El2.ONE INA COMPARTMENTED UNIT. �`vV Com l....P.gef.r each mm amment in titre unit DATE UST SYSTEM ST LED 435 TANK CAPACIa„'Y IN GAL j S 436 NUMBER OF COMPAR'�a4EN�S1N THE UNIT . 437 g� M.TANK USE AND CONTENTS (� C' TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ 1c.AVIATIONFUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(lavudes Und Oil) ❑ 5.EMERGENCY GENERATORFUEL IHSC§25231.5(c)I ❑ 6.OTHER GENERATOR FUEL Glaij.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: I] I,REGULAR UNLEADED ❑ 1c.MWORADE UNLEADED El1b.PREMIUMUNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ &PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (specify): 4aoe NON-PETROLEUM❑ T USED OIL ❑ METHANOL a-11.OTHER NON-PETROLEUMS glrop Y 4406 W. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 95.UNKNOWN 443 PRIMARY CONTAINIvENT ❑ I.STEEL ❑ 3.FIBERGLASS ❑ 6.E i tr AL BLADDER 444 ❑ 7.STEEL+INTERNALLINING 95.UNKNOWN ❑ 99.OTHER (Specify): a SECONDARY CONTAINMENT ❑ 1.STEEL ❑J.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE 95.UNKNOWN ❑99.OTHER(S ccf ): 445a OVERFILL PREVENTION ❑ L AUDBLE&VISUAL ALARMS ❑ ?•BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. 4.TANK MEETS REQUIRII WTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V..PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑].SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTIffiR 46m SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION [14.SAFE SUCTION E23 CM42636(a)riij 459 PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 [:190.NONE ❑ 95.UNKNOWN ❑ 99.0T'HER(S ecify): 464. SECONDARY CONTAINMENT �1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXBLE El10.RIGID PLASTIC 464. ❑ 90.NONE El 95.UNKNOWN [199.OTHER(Spccify): 464c PIPING/FURBINE CONTAINMENT SUMP TYPE ❑ I.SINGLE WALL ❑2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPO9 RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1,STEEL ❑ 4.FIBERGLASS ❑ 10,RIGID PLASTIC -Mj�QO.NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ]0.AIOID PLASTIC 90.NONE ❑ 99,OTHER(Specify) 444"f1n VR PRIMARY COMAJNMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ I0.RIGID PLASTIC �.90.NONE ❑ 99.OTHER(Specify) 4641 444 1 VRSEONDARYCONTAINMENT ❑ 1.STEEL FFIBERGLASS ❑ 30.RIGID PLASTIC �,90.NONE ❑ 99.OTHER(Specify) 464. 964.1 VENT PfPING TRANSTTION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 4641• ❑ 4.FIBERGLASS ❑ f0.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 4641 RISER PRIMARY CONTAINMENT 14 1.STEEL 464'1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ja 90.NONE ❑ 99.011MR(Specify) 464k 464ki FILL COMPONENTS INSTALLED 1.SPILL BUCKET F-13.STRII(ER PLATE/BOTTOMPROTECTOR 4.CONTAINMENT SUMP ulac VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONti CONSTRUCTION MfATERTAL 8 1.ETEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ K OTHER(Sped ) 4696-o VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL.ANODES) ❑ 4.RvTRESSED CURRENT ❑ 6.ISOLATION 443' DI. APPLICANT SIGNATURE CERTIFICATION: I cern. bats U ystem is compatible with the hazardous substamce stored and that the information provided herein is hue,accurate, and-Im full compliance ith I al re uirements. 470. APPLICAN ICNATURE DATE APP -*N1` )int) 471. APPLICANT UPCF UST-B-I/2 Rev.(12/2007)