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UNIFIED PROGRAM CONSOLIDATED FORM O 1 i0 $ UNDERGROUND STORAGE TANK Kt OPERATING PERMIT"PLICATION-TANK INFORMATION (One fmm per US'I) E OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections I,H I![,IV,and 6Ybe/aw) 430. 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION C ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430. 1 DATE E)USTINGUST DISCOVERED: 430 f� I. FACILITY INFORMATION /- f3 FACILITY[D P(Agency Use Only) BUSINESS NAME(Same as Facility N or DBA-Dot usiness As Ll 0 BUSINESS SITE ADDRESS 103CITY . (n al n P.r0. GI��t1� �. lAdy II. TANK DESCRIPTION TANK ID# -.:�i� J' 432 TANK MANUFACTURER 433. - TANK CONFIGURATION:THIS TANK IS 434. /rte LA STAND-ALONE TANK Cple4onepegefwea DATE UST SYSTEM INSTALLED 435. V I ONE INA COMPARTMENTED UNIT p eut in t una 1 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437. 2� 00 III. TANIUS ?ND.CONTENTS TANK USE U IuMOTORVEHICLEPUELMG O Ib.MARINA FUELING L ❑ 3.C IEMICAL PRODUCT STORAGE 0 5 EMERGENCY FUELING 439. 95.UNKNOWN WASTE(IndWes Used Oip ❑ S.EMERGENCYG);AkORFUEL[HSC§2528L5(43 ❑ 6.OTHER GENERATOR FUEL _ ❑ 95.UNKNOWN 0/99.ETHER(S ify): �..aP.4.J 04 ) 439a CONTENTS PETROLEUM: ❑ REGULAR UNLEADED ❑ la MIDGRADE UNLEADED 0 Ib.PREMIUM UNLEADED 440. ❑ 3.3.DIESEL �0 5 JET FUEL [I6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL t1Y9 OTHER PETROLEUM(Specify): n 440a NON-PETROLEUM:0 7,USED OI, 0 10.ETHANOL -------- ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV TANK CONSTRUCTION TYPE OF TANK I - --__ 1 SMGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT 1.STEEL ❑ 3.FIBERGLASS ❑ 6.EYlERNAL BLADDER - ❑ 7 STEEL+INTERNALLWEJG95. . SECONDARY CONTAINMENT .STEEL ❑ &EXTE IOR ❑ 99.OTHER(Specify): 7f 444a 03.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7,JACKETED ---445. _- _ ❑ 90.NONE ❑ 95.UNKNOWN ❑99,OTHER(Specify): 445a OVERFILL PREVENTION ❑ 1.AUDIBLE$VISUAL ALARMS 2.BALL FLOAT ❑ 3.FILL TUBE SHUT- OFF VALVE 451 ❑ 4.TANK MEETS REQUIREMENTS POR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT P1PINGcox PRODUCT/WASTE PIPING CONSTRUCTION SYSTEM TYPE UCTION SMGLE WALL_�.2 DOUBLE WALL ❑ 99.OTHER _ 460. _ _L PRESSURE _❑ 2.GRAVITY ----- ❑ 3.CONVENTIONAL SUCTION ❑ 4 SAFE SUCTION 23CCA 263 458. PRIMARY CONTASNMENT ❑ 1.STEEL - ❑ 4.FIBERGLASS --- -[._4 6(n)O)) ❑ 90.NONE ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 95.UNKNOWN ❑ 99.OTHER(specify)' 464x. SECONDARY CONCAEVMENT ❑ L STEEL 0 4.FIBERGLASS ❑ 8.FLEXBLE ❑ 10.RIGID PLASTIC 464h ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99 OTHER(Spec*); 4N4 PIPING INE CONTAINMENT SUMP TYPE ❑ I SINGLE WALL, UBLE WALL ❑ 90NONE 4644 V1. VENT, OR VAPRECOVERY(VR) AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1 TEEL ❑ 4,FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE 4N VENT SECONDARYCONTAINMENT I.STRFI ------ ❑ 99.OTHER(Specify): 464.1. ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE ❑ 99 OTHER(Specify): VR PRIMARY CONTAINbfII]T ❑ I.STEEL4641. ❑ 4.FIBERGLASS ❑ --RIGID PLASTIC ❑ 90. _ NONE 11 99.OTHER(Specify): VR SECONDARY CONTATNbfI%'Ni)T ❑ 1.STEEL ❑ 4.FIBERGLASS - ❑ Io. A ❑ 90.NONE ❑ 99.OTHER(Sp.*).): 4644M VENT PIPING TRANSITION SUMP TYPE 11 -,SINGLE WALL ❑ z,DOUBLEOUBLE WALL ❑ go.NONE � RISER PRIMARY CONTAINMENT 0 1,STEEL 0 4,FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 099,OTHER S ec' 464'. RISER SECONDARY CONLAIlsMIE1VT -- p ify): 4�" _ ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTUF_R(Spe.ify). 464k. FILL COMPONENTS INSTALLED ❑ I SPILL-BUCKET -- - 4fi4kL ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTA _N ENT SUMP 451u-c, _. VII .UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE_ _ ❑ 1.SINGLE wAr r. ❑ 2.DOUBLEWALL_ Els NO DISPENSERS _ ._ CONSTRUCTION MATERIAL ❑ 90 NONE 469-1 ❑ 1 STEHL ❑ 4 FIBERGLASS 0 HE RIGID PLASTIC ❑ 99.OTHER(Spac,fy) 4696. 469c. VIII. CORROSION PROTECTION STEEL CO.UIPONLTVT PROTECTION ❑ 2.SACRIFICIAL ANODES) ❑ 4.IMPRESSED CURftEN 1' ❑ 6ISOLAIION 448. ;LY. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate and in fullc with legal requirements APPLICANT SIGNATURE DATE D U 470. APPLICANT NAME(prmt) ' / 471' I APPLIC TTfLE7 s I 492. UPCF UST-B Rev.(12/2007)-1/2 LC www.unidocs.org G„--