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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 ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4103I DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID k(Agency Use Only) 1 BUSINESS NAME Same as FACILITY NAME or DBA-Doing Business As) 3 IC BUSINESS SITEADDRESSQ r,�. 103 CITY K II.TANK DESCRIPTION TANK ID 9 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 1 .. T.(t U G Co I.A STAND-ALONE TANK r.�-.tls I �(„� J ❑2.ONE IN A COMPARTMENTED UNIT. ✓v complete one a,for each eoma ent ie the unit. DATE UST SYSTEM INSTALLED 435 TANK C �C,jT,IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 III.TANK USE AND CONTENTS TANK USE �Lla.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE,pndodes U,ed 0.1) ❑ 5.EMERGENCY GENERATOR FUEL IHSC§252BIS(cH El6.OTHER GENERATOR FUEL El95.UNKNOWN ❑ 99.OTHER (Specify): 4393 CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 PC 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM Spccifyt 440. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ IL OTHER NON-PETROLEUMSpecify): 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL �2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 4443 SECONDARY CONTAINMENT ❑ 1.STEEL E&3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 4d5 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S eci ): 445. OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.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 El LSI �2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPELPRESSURE .2.GRAVITY [13.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(a)(3)] 458 PRIMARY CONTAINMENT 1.STEEL K 4.FIBERGLASS ❑ S.FLEXIBLE ❑ I0.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL W.4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. PIPINGlTURBINE CONTAINMENT SUMP TYPE ❑ LSINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ I0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641` VR PRIMARY CONTAINMENT -' 64f1.1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑90.NONE ❑ 99.OTHER(Specify) 4648 464 1 VR SECONDARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS I] 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE •I.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 464,. RISER PRIMARY CONTAINMENT 1.STEEL [14.FIBERGLASS [II0.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 4641 464;1 RISER SECONDARY CONTAINMENT 5 L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED L SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 4513-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE Id L SINGLE WALL -- .DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL IM 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER Specify) 4696-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 true,accurate, and in full compliance with legal requirements. A Nf SIGNATU / DATEzf _ 470 APPLICANT NAME( rint) I APPLICANT TITLE QP�IID�� e UPCF UST-B-112 Rev.(12/2007)