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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. For a UST c%sure or removal,complete only this section and Sections/,/L I//,fI',and LYbe/ow) 430. Jit I.NEW PERMIT ❑ 3.RENEWAL PERMIT 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 5.CHANGE OF INFORMATION DATE UST PERMANENTLY CLOSED: 430. S.UST REMOVAL DATE EXISTING UST DISCOVERED: 430N FACILITY ID#(Agency Use On/y) I. FACILITY INFORMATION D BUSINESSE(Same as Facili G Name or<)BA-Doing Btuiness As) iSsle_ 1wV-0 fe' 3. BUS SS SITE ADDRESS 103. CITY a/Ja a, e. t94. II. TANK DESCRIPTION TANK 1D# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. S bOQ �ria I.A STAND-ALONE TANK Corry in oce page fr xh DATE UST SYSTEM INSTALLED 435. TANK CAPACITY M GALLONS 436. 2.ONE INA COMPARTMENTED INIT campvenmt;n mewit NUMBER Of COMPARTMENTS IN THE UNIT 437. III. TANK USE AND CONTENTS TANK USE ❑ Is MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING _Q:t3.CHEMICAL PRODUCT STORAGE ❑ 4yAZARDOUSWASTE C] Ic.AVIATION FUELING 439. El , IndW®OrW OiI 6.OTHER GENERATOR FUEL ( ) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§M81.5(c)l CONTENTS ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439. PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic. n MIDGRADE UNLEADED IPREMIO ❑ 3.DIESEL ❑ 5.LET FUEL b' UNLEADED 440. ❑ 8.PETROLEUM BLEND FUEL 6.AVVIATIIATIONN GAS NON-PETROLEUM:❑ 7,USED OIL �&.OTHER PETROLEUM(Specify): A 440.7- [3F 10.ETHANOL 11 __ --------_ ❑ 11.OTHER NON-PETROLEUM(Specify), 4406. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.5 WGLE WALL 2.DOUBLE WALL PRIMARY CONTAINMENT _11&'1.STEEL ❑ INT KNOWN 443, ❑ 3.FIBERGLASS 6 INT ❑ 6. ERNAL BLADDER 444 ❑ 7.LSTEEL+WTERNALLINWG ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): aa4. SECONDARY CONTAINMENT.$I.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445. OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALLFLOAT ❑ 3.FILL TUBE SHIT-OFF VALVE - - ❑ 4.TANK MEETS RE UIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT 45±. V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 1.SINGLE WALL ❑2.DOUBLE WALL ❑ 99. SYSTEM TYPE $LPRESSURE OTHER 460. PRIMARY CONTAINMENT -�1.STEEL [3 2 GRAVITY 3 CONVENTIONAL SUCTION ❑ 4,SAFE SUCTION[±7 CCR§2 3)] 458. ❑ 4.FIBERGLASS M.FLEXIBLE ❑ I0.RIGID PLASTIC 461. ❑ E ❑ 95.UNKNOWN 1399 1.STEE .OTHER(Specify): a64. SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4,FIBERGLASS ❑ $,FLEXIBLE ❑ 10.RIGID PLASTIC 464h ❑ 90.NONE ❑ 95.UNKNOWN x'99.OTHER(Specify)' �p 4 (� 464a PIPING/I'URBINE CONTAINMENT$UMP TYPE ❑ I.S WGLE WALL ❑ 2.DOUBLE WALL ONE 4643 VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ I0,RIGID PLASTIC 90.NONE ❑ 99,OTHER5 4 VENT SECONDARY CONTAINMENT 4 l Peclh): 64el. ❑ 1.STEEL ❑ 4.FIBERG1A55 ❑ 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify): 464 VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS 4646. ❑ 10.RIGID PLASTIC m 90,NONE ❑ 99.OTHER(Specify): 464 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ q.FIBERGLASS 460 1, ❑ 10.RIGID PLASTIC Ij 90.NONE ❑ 99.OTHER(Specify): 064N VENT PIPING TRANSITION$UMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 19 90.NONE a64N1;. RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4,FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 464. RISER SECONDARY CONTAINMENT ❑ 99.OTHER(Specify): 464' ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID P[ASTIC B 90.NONE ❑ 99.OTHER(Specify): 464E FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.57RIKER PLATE/BOTTOM PROTECTOR 464k1. ❑ 4.CONTAINMENT SUMP 4510-c VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ I.SMGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS 90,NONE 469. CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ I0.RIGID PLASTIC ❑ 99.OTHER(Specify) 40tt469c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2,SACRIFICIAL ANDD 5) ❑ 4.1MPRESSED CURRENT 6.ISOLATION 448. IX APPLICANT SIGNATURE CERTIFICATION: I ceryfy that this U51 system is compatible with the hazardous substance stored and that the information provided herein is true, accurate and In fuB com Haoce with legal requirements APPLICANT SIGNATURE DATE 470, APPLICANT NAME(print) 471' 11 APPLICANT TITLE 47±. UPCF UST-B Rev.(12/2007)-1/2 "munidocs.org