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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form UST) / TYPE OF ACTION (Check one item only. Foran UST permanent closure or removal,complete only this section and Sections 1,I1,111,IV,and IX below) ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION fRM. PORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL PERMANENTLY CLOSED: °J0i DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID N(Agency Use Only) - - / S NAME(Same,As FACILITY NAME DBA-Doing Business AS) ^-� /, 3 UI,r r-t7 TJL., .e. A.-r\ tr r` I/SITE ADDRESS ..A.. `�� 103 II.TANK DESCRIPTION 432 TANK MANUFACTURER 433 TANKCONFIGURATION: THIS TANK IS 434 1.A STAND-ALONE TANK /�� ❑2.ONE IN A COMP RTMENTED UNIT. SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 III.TANK USE AND CONTENTS M TANK USE ❑ Ia.MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ Ic.AVIATION FUELING 439 >'3.CHEMICAL PRODUCT STORAGE Q 4.HAZARDOUS WASTE(include Ua q0 ❑ 5.EMERGENCY GENERATOR FUEL[HSC W281.5(c)] ❑ 6.OT HER GENERATOR FUEL ❑ 95.UNKNOWN Q 99 OTHER (Sped ): 439a CONTENTS PETROLEUM: ❑ la REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ W.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL 9.OTHERPETROLEUM (Specify): F, ,NON-PETROLEUM:Q 7USED OM ❑ l0ETHANOLI L OTHER NON-PETROLEUMS i : a40bIV. TANKCONSTRUCTIONTYPE OF TANK 1.SINGLE WALLQ 2.DOUBLE WALL ❑ 95.UNKNOWN 443PRIMARY CONTAR4119ENT 1.STEEL ❑ 3.FIBERGLASS 6.INTERNAL BLADD7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ i :SECONDARY CONTAINMENT - I.STEEL ❑3.FIBERGLASS Q 6.EXTERIOR MEMBRACKETED q45 90.NONE Q 95.UNKNOWN .OTHER(S ' ): apse OVERFILL PREVENTION I.AUDIBLE$VISUALALARMS 2.BALL FLOAT3.FH.L TUBE SHUT-OFF VALVE ase. 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 1.SINGLE-WALLED Q 2.DOUBLE-WALLED [199.OrrHER 460 SYSTEM TYPE 1.PRESSURE [12.GRAVITY 40 3.CONVENTIONAL SUCTION Q 4.SAFE SUCTION[23 CCR§263 3)] 458 PRIMARY CONI AINMENJ L STEEL ❑ 4.FIBERGLASS 8.FLEJ(IBLE 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN Q 99.OTHER(S Ity): 464a SECONDARY CONTAINMENT [II.5TEEL 4.FIBERGLASS S.FLEXIBLE15 10.RIGID PLASTIC 464. 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 469 PIPINGfrURBRVE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL Q 2.DOUBLE WALL 90.NONE 464d VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 L STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464e VENT SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 467f VR PRIMARY CONTAINMENT ❑ U 4.FIBERGLASS 0 10.RIGID PLASTIC4&1fl 90.NONE 99.OTHER(Specify) VR SECONDARY CONTAINMENT ❑ 1.STEEL U 4.FIBERGLASS 0 10.RIGID PLASTIC4M I 90.NONE 99.OTHER(Specify) VENT PIPING TRANSITION SUMP TYPE 11 I.SINGLE WALL 464hl 2.DOUBLE WALL 90.NONE 464. RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464) RISER SECONDARY CONTAIII... U I.STEEL U 4.FIBERGLASS 10.RIGIDPLASTIC 90.NONE 99.OTHER(Specify) Qb4k FILL COMPONENTS INSTALLED 1.SPILL BUCKET 7.STRIKER PLATE/BOTTOM PROkI TF71 4.CONTAINMENT SUMP SIQac VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL Q 3.NO DISPENSERS 90.NONE 469+ CONSTRUCTION MATERIALI.STEEL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION Ms. IX APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the informatlort proWded herein Is true,accurate, and fa!nB coin Bance with I al ulremenb. APPLICANT SIGNATURE DATE 4M. APPLICANT NAME(print) 47). APPLICANT TITLE 472, UPCF UST-9-1/2 Rev.(12/2007)