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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 430 ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION El 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) ^ BUS SS AME(Sa/111 e as FACILITY NAMEVA-D oipg Business As) 3 BUS SS I&E S 103 CITY 104 �i y II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TA�15 CONFIGURATION: THIS TANK 1S 434 A STAND-ALONE TANK 2.ONE IN A COMPARTMENTED UNIT. _ Z I y Complete one Me ror each com amenl in the unit. b&TE T STM INSTALLED 435 TANK CAPACITYGALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 f 2 oa > VIII.TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC 425281.5(c)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: -Ia.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED Ib.PREMIUM UNLEADED 440 ,_j 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ I.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER { 444 ❑ 7.STEEL+INTER AL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE 95.UNKNOWN ❑99.OTHER(Spec' ): 445a OVERFILL PREVENTION Aff I.AUDIBLE&VISUAL ALARMS El2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED [12,DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR§2636(a)(3)) 458 PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464& SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ l0.RIGID PLASTIC 464b ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT Ll 1.STEEL 4.FIBERGLASS [1l0.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464r 464n VR PRIMARY CONTAINMENT ❑ 1.STEEL 12 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464 1 VR SECONDARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS 13 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ff 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 464i. RISER PRIMARY CONTAINMENT JZ 1.STEEL ❑ 4.FIBERGLASS El 10.RIGID PLASTIC ❑ 90.NONE El 99.OTHER(Specify) 4641 464'I RISER SECONDARY CONTAINMENT 0 I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464kl FILL COMPONENTS INSTALLED 7I.SPILLBUCKET for 3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b c 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"Rrue,accurate, and in full compliance with legal requirements. _ APPLICANT SIGNATURE DATE ,�l � J 470. APPLICANT NAME(print) 471' APPLICANT TITLE �. 472. UPCF UST-B-1/2 Rev.(12/2007)