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S-/tii(-r L6 -rAo5zo8-o toms UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form net UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,It,III,[V,and IX below) 430 1.NEW PERMIT E33.RENEWAL PERMIT El 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430e DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION Q Z116 Y FACILITY ID#(Agency Use Only) 1 BUS S NA (Same asTY N or DBA- Ding Business As) 3 BUS ESS SITE D S 163 CITY too � II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK cONFIGUItATIoN: THIS TANK is 434 ❑I.A STAND-ALONE TANK /✓'� r I ��ONE M A COMPARTMENTED UNR. Com tete owe a efor each com artmmrin Me wit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 a 7 II.TANK USE AND CONTENTS TANK USE �Q Ia.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE andedes Used W) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§252815(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 43% CONTENTS PETROLEUM: ❑ la REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (specify): 44oa NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11,OTHER NON-PETROLEUM S mi ): 44eb IV. TANK CONSTRUCTION TYPE OF TANK ❑ LSINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN a4l PRIMARY CONTAINMENT ❑ L STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (specify): 444a SECONDARY CONTAINMENT ❑ L STEEL .FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER 5 445. OVERFILL PREVENTION `Q 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT .Q 3.FILL TUBE SHUT-OFF VALVE 452. ❑ T TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ L SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER 46a SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR 02636(a)(3)] 455 PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(S ify): 46a SECONDARY CONTAINMENT ❑ I.STEEL �4.FIBERGLASS ❑ 8.FLEXIBLE L310.RIGIDPLASTIC 464b 90. ❑ NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 46U PIPINGrrURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 90,NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL N,4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE (] 99.OTHER(Specify) 4Mf 464f1 VR PRIMARY CONTAINMENT L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE (] 99.OTHER(Speedy) 4645 46 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL M,4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Spaify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE 0 1.SINGLE WALL V 2.DOUBLE WALL ❑ 90.NONE 4641. RISER PRIMARY CONTAINMENT -19,1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 461, 4641 RISER SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Sp«ify) 464k 464kl FILL COMPONENTS INSTALLED L SPILL BUCKET 3.STRIKER PLATEBOTTOM PROTECTOR 4.CONTAINMENT SUMP 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL 15,2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHERS ofy) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 945. IX. APPLICANT SIGNATURE CERTIFICATION: 1 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 legal requirements. APPLICANT SIGNATURE DATE 470 APPLICANT NAME(print) 671- APPLICANT TITLE 472 UPCF UST-B-1R Rev.(12/2007)