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1-1 w n1 <br />FIED PROGRAM CONSOLIDATED FOW. 'Q <br />UNDERGROUND STORAGE TANK tom`' <br />OPERATING PERMIT APPLICATION -TANK INFORMATION (One t per UST) <br />TYPE OF ACTION (Check one item only. Fora UST closure or removal, complete only this section and Sections 1,11,111, IV, and IX below) 1000 430. <br />❑ L NEW PERMIT3. RENEWAL PERMIT [35. CHANGE OF INFORMATION <br />6. TEMPORARY UST CLOSURE 7. UST PERMANENT CLOSURE ON SITE 0 8. UST REMOVAL <br />DATE UST PERMANENTLY CLOSED: 430a 1 DATE EXISTING UST DISCOVERED: 430b. <br />I. FACILITY INFORMATION <br />FACILITY ID # (Agency Use Only) _ _t. <br />BUSINESS NAME as FacilityName A-Doi�Bus sAs) �y 1�i 3. <br />BU SIN SS AD KESS r 103. <br />Cy(y 104, <br />'5*c <br />H. TANK DESCRIPTION <br />TANK ID # 4111216NK MANUFACTURER 433. <br />/ �✓vT�D5�5(A rJ�gin HL�tnf �uf iOhf <br />TANK CONFIGURATION: THIS TANK IS 434 <br />�2. OSTAND-ALONE <br />EIN C MPARTMENTED UNIT C miL " <br />DATE UST SYST INSTALLED 435. TANK CAPACITY IN GALLONS 436. <br />t•�e ate' za�4 2oa� <br />NUMBER OF COMPARTMENTS IN THE UNIT 437, <br />III. TANK USE AND CONTENTS <br />TANKUSEa MOTOR VEHICLE FUELING E3 lb. MARINA FUELING [I 1c. AVIATION FUELING 439. <br />3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (E..i n UeN a0 ❑ S. EMERGENCY GENERATOR FUEL [HSC 125281.5(c)) <br />6: OTHER GENERATORFUEL _❑ 95. UNKNOWN__ _ 1399.OTHER (Specify): 439x. <br />CONTENTS PETROLEUM: --la`REGULAR UNLEADED 13 1.. MMGRADE UNLEADED ❑ Ib. PREMIUM UNLEADED 440. <br />❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS <br />13 8. PETROLEUM BLEND FUEL _O 9. OTHER PETROLEUM(�1�)_ <br />NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL <br />I L OTHER NON -PETROLEUMS 440 - <br />IV. TANK CONSTRUCTION <br />TYPE OF TANK E3 1. SINGLE WALL . DOUBLE WALL ❑_ UNKNOWN 443. <br />_ _ _95. __ <br />PRIMARY CONTAINMENT ❑ 1. STEEL 3. FIBERGLASS ❑ 6. INTERNAL BLADDER--------------- 44+ <br />❑ 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99.OTHER (Specify): 444+ <br />SECONDARY CONTAINMENT ❑ 1. STEEL gn FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED /45 <br />❑ 90. NONE LJ 95. UNKNOWN O99.0THER S 'fy): 445. <br />OVERFILL PREVENTION .AUDIBLE&VISUAL ALARMS IZ2.BALIFLOAT C33. FILL TUBE SHUT-OFF VALVE 452. <br />4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br />V. PRODUCT / WASTE PIPING CONSTRUCTION <br />PIPING CONSTRUCTION _�i. SINGLE WALL F2. -DOUBLE WALL ❑ 99. OTHER 460 <br />SYSTEM TYPE 1. PRESSURE ___J:J_2. GRAVITY _ ❑ 3. CONVENTIONAL SUCTION ❑ A SAFE SUCTION [v CCR g2636(e)(3)1 _ 458. <br />PRIMARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS X8. FLEXIBLE ❑ 10. RIGID PLASTIC 464 <br />_ ❑ 90. NONE ❑ 93. UNKNOWN ❑ 99. OTHER (Spectf I 464e. <br />SECONDARY CONTAINMENT ❑ L STEEL ❑ 4. FIBERGLASS W. IT EXIBLE ❑ 10. RIGIDPLASTIC 464b. <br />_ E3 90. NONE ❑ 95. UNKNOWN E_ 99.014E1(Specify): 46k <br />PIPING/TURBINE CONTAINMENT SUMP TYPE 75r4. SINGLE WALL 0 2. DOUBLE WALL rl 90. NONE 4644 <br />VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION <br />VENT PRIMARY CONTAINMENT ❑ L STEEL V; . FIBERGLASS [310. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify):; <br />VENT SECONDARY CONTAINMENT ❑ 1. STEEL M4. FIBERGLASS ❑ IO. RIGIDPLASn_C ❑ 90. NONE ❑ 99. OTHER (Spedfy): <br />VR PRIMARY CONTAINMENT ❑ ].STEEL fA. FIBERGLASS [3 J0. RJGID PLAsnC ❑ 90. NONE_ ❑ 99. OTHER (Specify): �& <br />_ <br />❑ 10. RIGIB PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 4wb. <br />VR SECONDARY CONTAINMENT [31. STEEL 04. FIBERGLASS <br />_ <br />VENT PIPING TRANSTRON SUMP TYPE ❑ I. siNGLE WALL ❑ 2. DOUBLE WALL Ce90. NONE Y '' <br />RISER PRIMARY CONTAINMENT ❑ 1. STEEL kV4. FIBERGLASS ❑ 10. RIGIDPLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 4&7; <br />RISER SECONDARY CONTAINMENT ❑ L STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC CM. NONE ❑ 99.OTHER(Spcify): 46otO <br />FILL COMPONENTS INSTALLED . SPILL BUCKET 3. STRIKER PLATEMOTTOM PROTECTOR W. CONTAINMENT SUMP. <br />VII. UNDER DISPENSER CONTAINMENT (UDC) <br />CONSTRUCTION TYPE _ 1. SINGLE WALL ❑ 2. DOUBLE WALL [1 3. NO DISPENSERS ❑ 90. NONE 46%+ <br />CONSTRUCTION MATERIAL. ❑ I. STEEL ❑ 4. FIBERGLASS lo. um PLAsnC. „ c3 OT71ER (specify) �. <br />VIII. CORROSION PROTECTION <br />STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT W6. ISOLATION 448 <br />IX. APPLICANT SIGNATURE <br />CERTIFICATION: I certify that this UST system is compalible wi the hazardous substance stored and that the information provided herein is true, <br />lecutatt:EFEE]ftomplialgewith legal re mens. <br />APPLICANT SIGNATUREDATE <br />/ �--y� 0 <br />a OI & 47 <br />APPLICANT NAME (pr' -De /7 ;.J 41' <br />APPLICANT TITLE �Oe 432 <br />I / <br />UPCF UST -B Rev. (1212007) -1/2 www.unidocs.org <br />