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x�UU � 'L RECEIVED <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMA HEALT <br /> "' E OF ACTION (Check one item only. For Pn UST permanent closure or removal,complete only.this section and Secti ns ,III,.Iy.,gyt),q(36e6ws-NT u0 <br /> ®].NEW PERMIT 3.RENEWAL PERMIT ❑ .CHANGE OF�INFO I�]VV�I�C <br /> 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE .UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED; °J0i DATE EXISTING UST DISCOVERED: 4301, <br /> FACILITY ID p(Agency Use Only) - - <br /> BUSINESS NAME{Same as FACILI1Y NA or DBA-Doing Business As) 3 <br /> �G <br /> BUS INESSSITEADDRESS <br /> 3S 1:?ai�g-5 <br /> TANK m N +3l TANK MANUFACIURER43J TA CON <br /> FIGURATION: Ttns TANK Is 434 <br /> qi'1 A STAND-ALONE TANK <br /> /< L.ONE IN A COMPARTMENTED UNIT. <br /> DATE UST SYSjFlM TALLED +35 �n1`I""` `�"Ch C1°" 1in NCpiL <br /> GG', TANK CAP RY IN GALLONS 436 NUMBER ODAPARTMENTS IN THE UNIT 437 <br /> w O�kJ� <br /> ❑ <br /> 6.OTHER GENERATOR FUEL ❑'4. <br /> TANK USE L4 Ia.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic AVIATION FUELMG a9 <br /> ❑ J.CHEMICAL PRODUCT STORAGE .HAZARDOUS WASTE McIW.Um Oil) ❑ 5.EMERGENCY GENERATOR FUEL(HSC§2528LgcE <br /> S.UNKNOWN L ❑ 99.OTHER (SP <br /> S ecify):CI 439. <br /> CONTENTS PETROLEUM: ❑ la.REGULAR UNLE ..e ❑ le.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 <br /> 1.DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S eci : k 44W <br /> NON-PETROLEUM:E) 7.USED OIL ❑ 10.ETHANOL <br /> 11.OTHER NON-PETROLBUM S eci 440b <br /> 3 - <br /> -. <br /> TYPE OF TANK I.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN +43 <br /> PRIMARY CONTAINMENT e$-'I.STEEL ❑ 3.FIBERGLASS 6.INTERNAL BLADDER 444 <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER cif : 4u. <br /> SECONDARY CONTAINMENT ❑ 1.STEEL 113.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 <br /> 90.NONE El 95.UNKNOWN ❑99.OTHERS eci 445. <br /> OVERFILL PREVENTION. 1.AUDIBLE @VISUAL ALARMS 2.BALLFLOAT 3.FILL TUBE SHUT-OFF VALVE 452. <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT iTJfl�tl cC <br /> PIPING CONSTRUCTION LSINGLE-WALLED (]2.DOUBLE-WALLED { <br /> ❑99.OTHER 460SYSTEM TYPE ❑ {,PRESSURE ❑ 2.GRAVITY 3.CONVENTIONAL SUCTION ❑ 4.SAFESUCTION 123 CCR 2636(a)(3) 459 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑T.FLEXIBLE ❑ 10.RIGID PLASTIC 464 <br /> A<90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4644 <br /> SECONDARY CONTAINMENT 1.STEEL, ❑ 4.FIBERGLASS ❑ e.FLEXIBLE 10.RIGID PLASTIC 464b <br /> ,�940.NONE ❑ 95,UNKNOWN ❑ 99 OTHER S eci ): 464c <br /> PIPING?URBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 461d <br /> - <br /> 5? <br /> VENT PRIMARY CONTAINMENT .STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4644 <br /> 46441 <br /> VENT SECONDARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 0.NONE 99.OTHER(Specify) 461f <br /> 464n <br /> VR PRIMARY CONTAINMENT LSTEEL 4.FIBERGLASS 10.RIGID PLASTIC .NONE U 99.OTHER(Speci%) 464g <br /> 464 1 <br /> VR SECONDARY CONTAINMENT1.STEEL {.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4Mh <br /> VENT PIPING TRANSITION SUMP TYPE 46+hh <br /> L SINGLE WALL 2.DOUBLE WALL NONE 4641. <br /> RISER PRIMARY CONTAINMENT d2s,1.STEEL U 4.FIBERGLASS Lj 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 4641 <br /> 4641 <br /> RISER SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4644 <br /> FILL COMPONENTS INSTALLED 0 1.SPILL BUCKET TECTOR 4.3.STRIKER PLATFIBOTTOM PROCOMAINMENT SUMP 464ki <br /> q l 451.4 <br /> CONSTRUCf10N.TYPE LSINGLE WALL ❑ 2.DOUBLE WALL <br /> LJ 3.NO DISPENSERS 90.NONE 469. <br /> CONSTRUCTION MATERIAL 1.STEEL0 4.FIBERGLASS 0 HI RIGID PLASTIC U 99.OTHER S S eci 4. 4691 c <br /> se <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLA710N q L 449. <br /> CERTIFICATION: 1 certify that yhls UST system 4 compatible with the haurdous substance stored and that the Information provided herein Is true,accurate, <br /> and In full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE /O L� / 470. <br /> APPLICANT NAME(p' f�S / 471' APPLIC TIT <br /> p C. <br /> UPCF UST-B-]/2 / Rev.(122007) <br /> l <br />