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l UNIFIED PROGRAM CONSOLIDATED FORM ' J�/W<c� UNDERGROUND STORAGE TANK ( OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. For an UST permaneot closure or removal,complete only this section and Sections I,II,lll,N,and IX below) 430 ❑ I.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE ns INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE DATE UST PERMANENTLY CLOSED: OS ❑ S.UST REMOVAL DATE EXISTING UST DISCOVERED: 4306 I. FACIIITYINFORMATION FACILITY ID#(Agency Use Only) - I BUSS NAME(S4a�me m FACILITY NAME cor DBA-Doing Business As) 'el V"trr-D C7i.4r ¢ Gh C-IiG .1/ nn 3 BUSINESS SITE ADDRES r r)S I ,� 9 0J CTIY tt, uY 104 II.TANK DESC ON TANK m# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 4 A STANDALONE TANK .ONE INA COMPARTMENTED UNIT, DA UST SYSTEM INSTALLED 435 TANK AC1TY IN GALLONS 4J6 C ae ms tl°1"etemut F' NUMBER OF COMPARTMENTS IN THE UNLIT 437 `v f`� IIIfl .TANK USE AND CONTENTS' `I TANK USE ❑ Is.MOTOR VEHICLE FUELING ❑ It.MARINA FUELING 3.CHEMICAL PRODUCT STORAGE ❑4.HAZARDOUS WASTE ❑ Ic.AVIATION FUELING 439 Ar ❑ 6.OTHER GENERATOR FUEL (a lme VeW UO ❑99.OTH5. R IS milENERATOR FUEL(HSC§252813(c)I I V I ❑ 95.IJN0 Ic.M ❑ 99,OTHER M NLE 4)9a CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED ❑ 3.DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS 'A ❑ B.PETROLEUM SLENDFUEL W 9.OTHER PETROLEUM $ ,7 _ ,Q r �� NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUMS i 4406 IV- TANKCONSTRUCTION TYPE OF TANK 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN PRIMARY CONTAINMENT A I.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 443 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER SECONDARY CONTAINMENT ^ 1.STEEL IS em 44G ❑3.FIBERGLASS ❑ b.EXTERIOR MEMBRANE LAYER q 7.Jq ❑ 445 90.NONE 0 95.UNKNOWN .OTHERS ): r OVERFILL PREVENTION 1.AUDIBLE&.VISUAL ALARMS 2.BALL FLOAT �'Sa J.FILL TUBE SHUT-OFF VALVE 451 4,TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION L SINGLE-WALLED ❑2.DOUBLE-WALLED 1399.OTHER SYSTEM TYPE I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION _3 CCR§2636(ax3) 4580 PRIMARY COMAfNMEN7 1.STEEL ❑ 4,FIBERGLASS S.FLEXIBLE ❑ 10.RIGID PLASTIC q6q 90.NONE ❑ 95.UNKNOWN 99.OTHER(Specify): 464a SECONDARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ S.FLEXD3LE ❑ 10.RIGID PLASTIC 4646 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464, PIPING?URSINE CONTAINMENT SUMP TYPE ❑ 1.SMGLE WALL ❑ 2.DOUBLE WALL VI.VENT,VAPOR RECOVERY 9o.NONE 4wa BE R);A S RISER/FILLPIPE PIPING CONSTRUCTION VENT PRIMARY COMAINMENT 1.STEEL 4.FIBERGLASS /0.RIGID PLASTIC 90.NONE 9M DTHER(Specify) 4440 VENT SECONDARY COMAINMENT ❑ I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 4 99,OTHER(Specify) 444r VR PRIMARY CONTAMMENT ❑ I.STEEL U 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 99.OTHER(S 4640 pacify) 464a VR SECONDARY CONTAI-11I ❑ LSTEEL U 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99,OTHER(Specify) 4Wb VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 464h1 RISER PRIMARY CONTAINMENT ❑ 1.STEELU 4.FIBERGLASS U 10.RIGID PLASTICN. 90.NONE 99..OTHER(Specify) 4 R15ER SECONDARY COMAINMENI 1.STEEL 4.FIBERGLASS 10.RIGIDPLASTIC 90.NONE . (Specify) 4541 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 0 3.STRIKER PLATE/BOTTOM PROTECTOR 4 CONTAINMENT SUMP 49 kl VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ L SINGLE WALL ❑ 2.DOOBLE WALL ❑ 7.NO DISPENSERS 90.NONE 4690 CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4,FIBERGLASS l0,RIGID PLASTIC ❑ Y9.OTHER(Specify) 969bc 121- CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that fast UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full com Lance with 1 el re uiremeats. APPLICANT SIGNATURE DATE 430. APPLICANT NAME(Print) 471. APPLICANT TITLE 472. UPCF UST-B-1/2 Rev.(12/2007)