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c� UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per LIST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,LB,IV,end IX below) 430 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 9301 DATE EXISTING UST DISCOVERED: 43ab I. FACII,I'fYINFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) > CNVc.+r-o 31 BUSINESS SITE ADDRESS iO3 "ITL H, e4 H.TANK DESCRIPTION TANK 11)# 432 TAMC MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 4 .A STAND-ALONE TANK ❑2.ONE IN A COMPARTMENTED UNIT. DATE UST SYSTEM INSTALLED 435 C°"' "°°"` rO""A .a"+em in me wuc /r TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 2� M.TANK USE AND CONTENTS' TANK USE ❑ Ia.MOTICAL PRCLEFUETOR ❑ Ib.MARINA FUELING ❑ Ic.AVWTION FUELING 439 '( °W]3 CHEMICAL PRODUCT'STORAGE ❑ 4.HAZARDOUS WASTE Ocdu6e Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC 425=81.5(c)I ❑ 6.OTHER GENERATOR FUEL [395.UNKNOWN ❑ 9W9.OTHER(S ify): 43% ED CONTENTS PETROLEUM: ❑ la.REGULAR UNLEAD ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 IMS ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS •I e ❑ 8.PEIOLEUMBLENDFUEL ❑ 10.9.OTHERPETROLEUM S /a �Sa-/SSIh.� 440a NON-PETROLEUM:❑ 7.USED OIL ETHANOL /� Cl 11.OTHER NON-PETROLEUM 8 i : I4.rf ybb IV.TANKCONSTRUCTION TYPE OF TANK L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN PRIMARY CONTAINMENT W 1.STEEL [j443 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER S 444a SECONDARY CONTAINMENT 1.STEEL ❑3.FIBERGLASS ❑ 69 EXTERIOR MEMBRANE LINER Q 7.IACKETED aas NONE ❑ 95.UNKNOWN .OTHERS ): IA 445a OVERFILL PREVENTION 1.AUDIBLE d VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-0rr VALVE 452 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 1.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE LJ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ I.SAFE SUCTION 23 CCR$2636(.X3) 458 PRNIARY CONTAINMENT 1& STEEL ❑ 4.FIBERGLASS 8.FLEXIBLE U I0.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN 99.OTHER(Specify): 4fi4a SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. PIPING li'IJRBINL+COMAINMEMSUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT U 1.STEEL U 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464e VENTSECONDARY CONTAINMENT Li I.STEEL U 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.OTHER(OTHER(Specify)SP c' 464f LJ VR PRIMARY CONTAINMENT[NM1IB1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464g VR SECONDARY COMANT ❑ 1.STEEL4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER S 464 1 (Specify) 464h VENT PIPING TRANSITION SUMP TYPE 111.SINGLE WALL 2.DOUBLE WALL 90.NONE 4 hl RISER PRIMARY CONTAINMENT I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464j RISER SECONDARY CON, U 1.STEEL U 4.FIBERGLASS TTIO.RIGID PLASTICl 90.NONE 99.OTHER(Specify) 461 FILL COMPONENTS INSTALLED W L SPILL BUCKET U 3.STRIKER PLATEMOTTOM PROTECTOR4.CONTAINMENT SUMP 451.1 VII.UNDER DISPENSER'CONTAINMENT aura CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS 90.NONE 469+ CONSTRUCTION MATERIAL ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIG,PLASTIC ❑ 99.OTHER(S i ) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448, IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in fuB cam Bance with I al re ulrements. APPLICANT SIGNATURE DATE 470, APPLICANT NAME(print) 471. APPLICANT TITLE 472. UPCF UST-B-1/Z Rev.(122007)