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UNIFIED PROGRAM CONSOLIDATED FORM �( UNDERGROUND STORAGE TANK o 13 l OPERATING PERMIT APPLICATION-TANK INFORMATION (One fam3 per UST) OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections L ll 114!V and6Ybelow) 430. I,NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION Lj 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 43oa DATE EXISTING UST DISCOVERED: 43a,. I. FACILITY INFORMATIO . FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as F c'1' Name or -DoingBusine_ss A,$) 3 BUSINESS SITE ADDRESSoq� ( t�innC IUnL�1TC-� . 103. CITY CIC (( V ' II. TANK DESCRIPTION TANK ID# N OS, 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. t4 r4- 6�/ 1/7tln n DSA STAND-ALONE TANK compel pge forcach 1 V` ❑ 2.ONE IN A COMPARTMENTED UNIT imp .t m Ne unit DATE UST SY TE INSTALLED 435. T CAPAC aIN GAL NS NUMBER OF COMPARTMENTS IN THE UNIT 437. Cl 5 gp III. TANK USE AND CONTENTS r 3 TANK USE ❑ Ia.MOTOR VEHICLG FUELMG ❑)b.MARINA FUELING ❑ Ic.AVIATION FUELING d439 ❑ 3.CHEMICAL PRODUCT STORAGE 4.HAZARDOUS WASTE(Indudes UaW aO EMERGENCY GENERATOR FUEL DISC§25281.5(.)] ❑ 6.OTBER GENERATOR FUEL ❑ 95.UNKNOWN ,OTHER(Specify): 439a CONTENTS PETROLEUM: El ]a.REGULAR UNLEADED 11Ic,MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS O 8,PETROLEUM BLEND FUEL__❑ 9.OTHEFPETROL_EOM(Specify): 440a NON-PETROLEUM:,❑,�/7.-USED ❑ 10.ETHANOL -- 14yi1.OTHERNON-PETROLEUM(S ecifS (JJ)<}j � �C 4406. W. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL _ 2 DOUBLE WALL ❑ 95 UNKNOWN 443. PRIMARY CO NTAINMENT --- _..... I.STEEL ❑ 3.FIBERGLASS ❑ 6.IMERNAL BLAD�DER� �t 444. 7.STEEL+INTERNAL LINING ❑ 95 UNKNOWN L§rvv OTHER(Sp ify):AA-107j:.,-rp)4-tnno� SECONDAR1.STEEL ❑3.FIBERGLASS [1 6.EXTERIOR MEMBRA��LINER qq 7.JACKETED 445. _ _ 90.NONE ❑ 95,UNKNOWN GK9.OTHER(Soecify): /y(Q$)7�-Pdu f"a.41K 44sa _ OVERFILL P 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALLFLOAT ❑ 3.FILL TUBE SHUT FF VALVE 4.TANK MEETS RE UIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT f _ V: PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 1 SINGLE WALL ❑ 2.DOUBLE WALL (] 99.OTHER 460. - .-.-.._ ...-._ ---...------_ _.-- --.--.-__. -_-_--_...-_...-- SYSTEM TYPE 1.PRESSURE _ ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4,BATE SUCTION[23 CCR 62W6(aX3)] 458. PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464. ❑90.NONE ❑ 95,UNKNOWN ❑ 99.OTHER(Specify): 464. SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ ]0.RIGID PLASTIC 464b. ❑ 90.NONE _ ❑ 95,UNKNOWN ❑ 99.OTHER(Specify): 464. PIPINGIPURBINE CONTAINMENT SUMP TYPE ----�--_ [ ❑ 90.NONE -----464d ❑ L SNGLE WALL ❑ 2.DOUBLE WALL VI_VENT,VAPOR RECOVERY (VR) AND RISER/FILL,PIPE PIPING CONSTRUCT_ION VENT PRIMARY CONTAINMENT [11.STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC [190,NONE El99.OTHER(Specify): _ 4��_ VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464f 464f1. VR PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify):-4 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [199.OTHER(Specify): h 46451. VENT PIPING TRANSTTION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WAtb [190.NONE 4"i RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10,RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4M' 464', RISER SECOA�D.ARY CONTAINMENT ❑ 1.sTeeL ❑ 4.FlBexcLAss ❑ la.wcm PLASTIC ❑ 90.NDNE ❑ 99.OTHER(Specify): °� _._. _._ 461k1. FILL COMPONI.NTS iNSTALLID ❑ 1.SPILL BUCKET ❑ 3.STRBCER PLATETIOTTOM PROTECTOR ❑ 4.CONTAINMENT-SUMP 451a-c. VII. UNDER DISPENSER CONTAINMENT (UDC) ,CTION IYPE LJ ❑ 2„DOUBLE WALL t CONSTRU _ _ ❑ 3.NO DISPENSERS CONSTRUCTION NIATHRL4L ❑ I.STEEL ❑ 4-FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 99.OTHER(SpccJy) 4696. 469, VIII. CORROSION PROTECTION STEELCOMPONENT PROTECTION ❑ 2.SACRIFICI--4L ANODES) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATTOS 448.= M APPLICANT SIGNATURE CERTIFICATION: I certify that this UST syste is compatible with the hazardous substance stared and that [he informn[ioa prorided herein is [rue, accurat a in full c e with le uirements. APPLICANT SIGNATURE DATE 9 470. APPLICANT NAME(print) /1/NSA 471' APPLicANt TITLE Lel L' (/�/) A - , 471. UPCF UST-B Rev.(12/2007)-112 U www.un§docs.org