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00 (To <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK ( O <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) <br /> TYPE OF ACTION (Check one item only. For a UST closure or removal.complete only this section and Sections 1,A 111.IV,and IXbelow) 430. <br /> I.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ S.CHANGE OF INFORMATION <br /> 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8,UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: ---- DATE EXISTING UST DISCOVERED: Lt 43on <br /> FACII.ITY ID#(Agency Use Only) I. FACILITY INFORMATION_ _ O r <br /> BUSINESS E(Same as Facili Name or DBA-Doing Business As) 3 <br /> G 4SP ' PW ro fei <br /> BUS SS SITE ADDRESS 103. CITY _ // 10q <br /> pekA <br /> H. TANK DESCRIPTION <br /> TANK ID# r7y� m2. [AAN��K MANUFACTURER I 433. TANK CONFIGURATION:THIS TANK IS aJ4. <br /> ��� ✓ LOr���nnM'r-SD�N"nuI.ASTAN0.ALONE TANK Co�lneom page forcad� <br /> DATE UST SYSTEM INSTALLED 435. ! ❑ 2.ONE M A COMPARTMENTED UNIT cwnprmnrnrin NeuniL <br /> TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS INTHE UNIT 437. <br /> M. TANK USE AND CONTENTS <br /> TANK USE ❑ la.MOTOR VEHICLE FUELING 0 Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439. <br /> _AiL-3.CHEMICAL PRODUCT STORAGE 04.HAZARDOUS WASTE(mdudrn Und,,) 05.EMERGENCY GENERATOR FUEL IHSC¢25'_81.5(c)] <br /> ❑ 6.OTHER GENERATOR FUEL 0 95.UNKNOWN ❑ 99,OTHER(Specify): 439. <br /> CONTENTS PETROLEUM: 0 la.REGULAR UNLEADED 0 Ic,MIDGRADE UNLEADED 0 It.PREMIUM UNLEADED 440. <br /> ❑ 3.DIESEL 0 5.JET FUEL fl 6.AVIATION GAS <br /> 0 8.PETROLEUM BLEND FUEL 9 OTHER PETROLEUM(Specify} (�V�-� „y fyr_�4( 440. <br /> NON PETROLEUM.0 7.USED OIL ❑ 10.ETHANOL --""- <br /> ❑ <br /> 11.OTHER NON-PETROLEUM(S ify): 44pp <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK 0 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443. <br /> PRIMARY CONTAINMENT -bl„et.STEEL 0 3.FIBERGLASS ❑ 6.INTERNAL BLADDER qpq, <br /> ❑ 7.STEEL+INTERNAL LINING 0 95.UNKNOWN 0 99.OTHER(Spmifyy 444x. <br /> SECONDARY CONTAINMENT Ail.STEEL 03.FIBERGLASS 0 6.EXTERIOR MEMBRANE LINER C 7,JACKETED - 445. <br /> ❑ 90.NONE 0 95.UNKNOWN 099.OTHER(Soecify); 445. <br /> OVERFB.L PREVENTION ❑ 1.AUDIBLE$VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. <br /> ❑ 4.TANK MEETS RE UIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION E UIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> ESECONDARY <br /> G CONSTRUCTION -_ L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 99.OTHER 460, <br /> EM TYPE �'I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION 0 4.SAFE SUCTION[23 CCR g2636(aX3H 458. <br /> ARY CONTAINIvINM 1.STEEL ❑ 4.FIBERGLASS M.FLEXIBLE ❑ 10.RIGID PLASTIC 464. <br /> 0 90.NONE 0 95.UNKNOWN 0 99.OTHER(Specify); 464. <br /> CONTAINMENT 0 I,STEEL 0 4.FIBERGLASS 0 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646, <br /> ❑ 90.NONE 0 95.UNKNOWN x'99.OTHER(Specify): Ovsew fL l.J y(� 464. <br /> GITURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 4644 <br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL 0 4,FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify): 4Ne' <br /> VENT SECONDARY CONTAINMENT464`1' <br /> ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 64 <br /> 464a <br /> VK PRIMARY CONTAINMENT <br /> ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RICK)PLASTIC m 90.NONE 0 99,OTHER(Specify), <br /> VR SECONDARY CONTAINMENT 0 L STEEL 0 4.FIBERGLASS 0 10.RIGIDPLASTIC g 90.NONE 0 99.OTHER(Specify): 464A <br /> VENT PIPING TRANSITION SUMP TYPE464n1. <br /> ❑ 1.SINGLE WALL 0 2.DOUBLE WALL 90,NONE 4641 <br /> RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 464 <br /> RISER SECONDARY CONTAINMENT 0 1,STEEL LJ 4.FIBERGLASS 0 10.RIGID PLASTIC [S 90.NONE 0 99.OTHER(Specify): 4k l <br /> FILL COMPONENTS INSTALLED <br /> t <br /> 464tL <br /> ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451ea <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ❑ LSWGLE WALL 02.DOUBLE WALL 03.NO DISPENSERS 90.NONE 469. <br /> CONSTRUCTION MATERIAL 0 L STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696.069c <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4,IMPRESSED CURRENT IR 6.ISOLATION 448. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, <br /> accurate and in full com liance with legal requirements. <br /> APPLICANT SIGNATURE DATE 470. <br /> APPLICANT NAME(print) 471. APPLICANT TITLE 47z. <br /> UPCF UST-El Rev.(12/2007)-112 www.unidoes.org <br />