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UNIFIED PROGRAM CONSOLIDATED FORM �/ UNDERGROUND STORAGE TANK a �l7JIl�V OPERATING PERMIT APPLICATION-TANK INFORMATION l((One form per UST) VIE OF ACTION (Check one item only. For a UST closure or removal,complete only the section aad Sections 1,Ll 111,lP 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: 430. DATE EXISTING UST DISCOVERED: 430h. I. FACILITY INFORMATION FACILITY ID 9(Agency Use Oaly) 1. i l 'i,c BUSINESS NAME(Same as Facility Na e or DBA- of asiness As) 3 BUSINESS SITE ADDRESS 11 t LL/I'1 4 103. CITY I04 IWa ^ II. TANK DESCRIPTION TANK IU� �/ 84Qi3 43^. TANK MANUFACTURER 433 T,4HK CONFIGURATION:THIS TANK IS 4M4 ' LA STAND-ALONE TANK C'Omple[e ovepagc fet each DATE UST SYS M INSTALLED 435. ❑ 2.ONE IN A COMPARTMENTED UNIT Iumnmtiv the mit TANK CAPACITY IN GALLONS 436, NUMBER OF COMPARTMENTS IN THE UNIT 437. 5 50 1 III. TANK USE AND CONTENTS TANK USE ❑ Ia.MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ Ic,AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Ivd.d.Us.d Oil) ❑�5 EMERGENCY GEN'ERATO FUEL[HSC j2t7815(c)] El6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN W 99.OTHER(Specify): ) 439. CONTENTS PETROLEUM: ❑ ]a.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS -_Q.8.PETROLEUM BLEND FUEL 9.OTHER PETROLEUM(Specify): 440a NON-PETROLEUM:❑ 7 USED OIL - - "' �� ❑ IO.ETHANOL ...._.._._....__ LKII.OTHERNON-PETROLEUM(5 ect ). 1rs4Ay tv cQaW^ 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1_SINGLE WALL W2.DOUBLE WALL ,095 UNKNOWN 443, PRIMARYCONTAINMENT ❑ 1.STEEL ❑ 3.FIBERGLASS 0 6 INTERNAL BLADDE& -- EI7_STEEL+INTERNAL LINING ❑ 95 UNKNOWN T19.OTHER( ity): 0/R/Jtt 444a SECONDARY CONTAINMENTFIB-ERG-LAS-S- ----- -- ❑ 1.STEEL ❑3. ❑ 6.EXTERIOR MEMS E LINER ❑ 7,JACKETED 4a5. _ ❑ 90.NO 0 95.UNKNOWN [ 9.OTHEA(�_fy) jL 445. OVERFILL PREVENTION El1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 451. ❑ 4.TANK MEETS RE UIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION E UIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION SINGLE WALL- ❑ 2.DOUBLE WALL _�-99 OTHER_ 460. SYSTEM TYPE -- ..._- (_PRESSURE ❑ 2.GRAVITY [13.CONVENTIONAL SUCTION El 4 SAFE SUCTION[23 CCR 4_636(a)(3)] _ 458 PRIMARY CONTAINMENT 0 1 STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 16.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. ._. -..--_ -_ SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646- [I90.NONE ❑ 95 UNKNOWN _ ❑ 99 OTHER(Specify)_ 464. PIPINGRURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE ----46,ic, VI. VENT, VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4Me' VENT SECONDARY CONTAINMENT ❑ 1.STEEL El4.FIBERGLASS El10.RIGID PLASTIC El90.NONE ❑ 99.OTHER(Specify): 400. VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90_NONE ❑ 99.OTHER(Spxify) VR SECONDARY : Zt�4g -.. - -..._ -.-_..- 469 CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4Mh VENT PIPING TRANSITION SUMP TYPE_ ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE RISER PRIMARY CONTAINMENT - __- ❑ LSTEEL ❑ 4.FIBERGLASS ❑ ]O.RIGHMASTIC ❑ 90,NONE ❑ 99 OTHER(Specify): RISER SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4Mk FILL COMPONENTS INSTALLED - "- - -- -- 464k1. ❑ I.SPILL BUCKET ❑ 3.STRIKER PLATEIBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a-c-- VIL UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ I SINGLE WALL __❑ 2 DOUBLE WALL El 3.NO DISPENSERS ❑ 90.NONE 469. CONSTRUCTION MATERIAL ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) - 4696 69, 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, accura a in fu om nce with legal requirements. APPLICANT SIGNATURE DATE G v 470 APPLICANT NAME(print) L 471 gpPLIC TITLE /� , !� an. UPCF UST-B Rev.(12@00')-12 G www.unidocs.org �K C/�--