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3_ <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND <br /> ORAGE TANK <br /> PERATING PERMIT STOAPP I <br /> TYPE OF ACTION (Check one item only. For UST closure or remova[LICATION- T end ANKons 1,11.IQlf;andlXbelow) y� <br /> W•NEW PERMITnly INFORMATION (One form per UST) <br /> th <br /> 0 6.TEMPORARY UST CLOSURE E2 3.RENEWAL PERMIT <br /> DATE UST PERMANENTLY CLOSED: UST PERMANENT CLOSURE ONSITE E) 5.CHANGE OF INFORMATION �2 <br /> 430a0 S-USTREA401, O <br /> DATE EXISTING UST DISCOVERED, <br /> FACILITY II. FACILITY INFO 430" <br /> D p(Agency Use Only) INFORMATION - <br /> BUSINESS N <br /> AME t(S^ame as Facility Name ar DBA_ om B,(y,NeS,sAs) <br /> BUSINESS STTE ADDRESS tt ^ 3. <br /> °1 SfioClCfiw� I� <br /> TANK ID x II.432 TANK DESCRIPTION <br /> 11 MANUFACTURER 433, TANK CONFIGURATION TFIIS TANK IS <br /> DATE UST SYSTEM INSTALLED 1435. C. <br /> h ^^ 56I �I art.A STAND-ALONE TANK <br /> qy <br /> TANK CAPACITYGin'r GLONS 436. ❑ PA <br /> 2.ONE IN COMRTMENTED UNIT camparcnmtm Nc u�ulazh <br /> �� S O NUMBER OF COMPARTMENTS IN THE UNIT 43T <br /> TANK USE L IN• TANK USE AND`CONTENTS <br /> ❑ ]a.MOTOR VEHICLE FUELING - ' <br /> ❑ 3.CHEMICAL PRODUCTS OR' II 16.''A 1. AFUELING ❑ 1c.AVIATION FUELING <br /> ❑ 6.OTHER GENERATOR FUEL I] 4'HAZARDOUS WASTE(Includes UsN Oo ❑�5,EMERGENCY GE LING 439 <br /> CONTENTS PETROLEUM: ❑ 95.UNKNOWN TOR FUEL(HSC 42528L5(cp <br /> ❑ la.REGULAR UNLEADED 99�OTHER(Specify); , i 439a <br /> ❑ 3.DIESEL ❑ ]c.MIDGRADE UNLEADED ❑ 16.PREMRIM UNLEADED <br /> __ Q 8.PETROLEUM BLEND FUEL FUEL ❑ 6.AVIATION GAS 440. <br /> NON-PETROLEUM:0- 7.USED 0-- jl---'"-' 9.OTHER PETROLEUM(Specify):.,_EP Q.Y O I <br /> ❑ 10.ETHANOL 440a <br /> ❑ <br /> 11 OTHER NON-PETROLEUM <br /> OWN <br /> TYPE R TANK ❑ L SINGLE WALL 2.DOUBLE WALL _ <br /> IV. TANK CONSTRUCTION <br /> PRN4AY CONTAINMENT Wn-STEEL ❑ 9s.UTKNOWN _ <br /> El7.STEEL+ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER - -- "-- - ,_ 443. <br /> SECONDARY CONE INTERNAL LINING ❑ 95.UNKN444. <br /> AINMQ.I'T I.STEEL Ll 3.FIBERGLASS ❑ 99,OTHER(SPwify): 444a <br /> El 90.NONE ❑ 95.UNKNOWN ❑ 6.EXTERIOR MEMBRANE LINEA ❑ 7.JACKETED - <br /> ❑99.OTHER(S ify)..ec445. <br /> OVERFILL PREVENTION ❑ I.AUDIBLE&VISUAL ALARMS 2.H 445a <br /> ❑ 4.TANK MEETS RE UIP.ESfE\7S FOR EXEMPTION FROM OVERFILL _PREVE INT ON EQUIPMENT <br /> AL� 452. <br /> QCT/WASTE PIPING CONSTRUCTION <br /> PIPING Z I.SINGLE WALL 2,DOLBLE WALL <br /> ..- ---.-_ ._. „99.OTHER , <br /> SYSTEM TYPE_ 5I?'7.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION 460. <br /> PRIMARY CONTAINMENT L STEEL q.FIBERGLASS S.FLEXIBLE I] 4.SAFE SUCTION 23 CCR 426 a)(3) 459. <br /> 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(S mity): 10.RIGID PLASTIC 464 <br /> SECONDARY CONTAAIMENT ❑ I.STFFl, ❑ 4.FIBERGLASS ❑ S.FLEXIBLE 464a <br /> 0 90.NONE E39AUNKNOWN _ EJ99.OTHER(Specify): IO.RIGID PLASTIC 464h <br /> PIPINGf1URBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL - 46rc. <br /> ❑ 2.DOUBLE WALL ❑ 90.NONE -----' <br /> VI. VENT, VAPOR RECOVERY_ 0 <br /> - (VR) AND RISER./FILL PIPE,PIPING_ CONSTRUCTION <br /> VENT PRIMARY COI IALNMEtNT fij7l.STEEL ❑ 4,FIBERGLASS ❑ 10.R10M PLASTIC ❑ 90.NONE . <br /> VENT SECONDARYCONfAINMENP 1. ._. 99._OTHER(Specify): <br /> 464, <br /> 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 4 <br /> 90.NONE ❑ 99.OTHER(Specify): 464E <br /> VR PRIMARY CON7ARA¢tJT O LSTEEL ❑ 4-I'MERGLASS ❑ 10.RIGIDPLASTIC4648 <br /> VR SECONDARY ODNI'ARiMENT ❑ 90.NONE ❑ 99.OTHER(Spxify): 464 <br /> Q LSIEFI, ❑ 4.FIBERGLASS90.NONH [199.OTHER(Specify): 4 M <br /> ❑ 10.RIGID PLASTIC 13h <br /> VENT PIPING TRANSIRON SUMP TYPE ❑ 1.SINGLE WALL ❑ 90.NONE 4 hi. <br /> ❑ 2.DOUBLE WALL <br /> RISER PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHERS ---__- -- 4 - <br /> 0 4.FIBERGLASS p ify)' <br /> RICER RFCONDARYCO]7A N1.dFNT c-= 46,61. <br /> I FILL COMP ONENT'S INSTALLED ❑ I.SPILL BUCKET IE 10 AIGIBOTTO IC ❑ 90.NONE ❑ 99 OTHER(Specify): 44Mkk <br /> .. ¢ ❑ 3 STRIKER PLATE/BOTTOM PROTECTOR ❑ 4 CONTAINMENT SUMP 451a-,, <br /> VII. UNDER DISPENSER CON <br /> TAINMENT (UDC)' <br /> CONSTRUCTION TWE _ ❑ 1,SINGLE WALL _ ❑ 2 D_OUB_LEWALL <br /> CONSTRUCTION MATERIAL ❑ 99,O7HEIzDISP�NS�S - 90 \ON_E _ 469, <br /> ❑ L STEEL ❑ 4.FIBERGLASS - 9 NO HELP <br /> ❑ 10.RIGID PLASTIC (Spec�ly) 469h <br /> VIII. CORROSION PROTECTION 69<. <br /> STEEL COMPONENT PROTECTION ❑ 2 SACRIFICIAL A.NODE(S) ❑ 4.IMPRESSED CCRREN l' <br /> -- ❑ 6.ISOLATION Jag. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that[his UST system is compatible with the hazardous Substance stored and that the information provid <br /> accurate an in full en I- nee with le at r uirements. ed herein is true, <br /> APPLICANT SIGNATURE DATEL q 470, <br /> APPLICANT NAME(print) O� 47t. L` <br /> APPLIC TITLE JlG` �YL 472. <br /> UPI UST-B Rev.(1212007)-1/2 www.unldocs.org <br />