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FIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK _P0.7_ OPERATING PERMIT APPLICATION-TANK INFORMATION ( e fot�i\per usT� TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,A 111,IR and 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: 4JQa I DATE EXISTING USTDISCOVERED 439b. 5107 D I. FACILITY INFORMATION FACILITY ID p(Agency Use Only) _ _ t. BUSINESS^NAME(Same as Facili Name or DBA-Doing Business As) 3 r'.J,�vy--or g ice! �Gl�,vte� BUSINESS SITE DRESS J �//� CITY / IW II. TANk DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434 L A STAND-ALONE TANK C.'c.one peae fcr.6 (n�NP'"'-- ❑ 2.ONE IN A COMPARTMENTED UNIT wmpemmem m Ne unit. DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437 III. TANK USE AND CONTENTS TANK USE ❑ Ia.MOTOR VEHICLE FUELING ❑ Ib.MARINAFUELING ❑ I c AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE Mcludu used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§2528L5(c)I ❑ 6 OTHER.GENERATOR.FUEL ...1511)5 UNKNOWN ___________ ❑ 99..OTHER(Specify)_ 439e CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ to.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 449% -- NON-PETROLEUM.El 7.USED OIL ❑ 10.ETHANOL ^ ❑ 11.OTHER NON-PETROLFUM(Specify), 4496 IV. TANK CONSTRUCTION TYPE OF TANK ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 3.FIBERGLASS ❑ 6 INFERNAL BLADDER 444. ❑ 7.STEEL t INTERNAL LINING,_ ❑ 95 UNKNOWN ❑ 99.OTHER(Specify)'. 441a SECONDARY CONTAINMENT ❑ 1.STEEL [13.FIBERGLASS ❑ 6 EXTERIOR MEMBRANE LINER ❑ 7.JACKETED N5. _ __ ❑ 90:,NONE -[1 95 UNKNOWN ❑99 OTHER(Specify) 445a OVERFILL PREVENTION ❑ 1 AUDIBLE&VISUAL ALARMS ❑ 2.BALL ❑ 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT /WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALT. ❑ 99.OTHER 469 SYSTEM TYPE ❑ 1 PRESSURE O 2 GRAVI FY ❑,3 CONVENTIONAL SUC"PION ❑ 4 SAFF.SUCTION 123 CCR 42636(e)Q)),,.--__458. PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4w. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 46411 SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4 FIBERGLASS ❑ 8.FLEXIBLE ❑ NFRIGIDPLASTIC 4wb. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify)'. 4a4c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644. VI. VENT, VAPOR RECOVERY(VR) AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4� 464 1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): qNflf VR PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90.NONE ❑ 99,OTHER(Specify): 464, 46s VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4 FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): <°4661 VENT PIPING TRANSITION SUMP TYPE ❑ I SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4841. __.. _...-.__ .-.-._.-_-. _.. _ _... __. _..-___-_- ..___. RISER PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify)' q4�' RISER SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ I0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 82111' _ ____-.__- ..__.._____...__.._...__.._..__..__..._...........____.....................__._......._.______ FILL COMPONENTS INSTALLED ❑ I.SPILL BUCKET ❑ 3.STRIKER PLATE/BOT'fOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 46911 CONSTRUCTION MATERIAL ❑ I.Sl'EEL ❑ 4.FIBERGLASS ❑ I0.RIGID PLASTIC ❑ 99.O"I'HER(Specify) ; VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION a48- IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate and in full compliance with legal requirements. APPLICANT SIGNATURE DATE 4J0, APPLICANT NAME(print) 471. APPLICANT TITLE 472- UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.9rg