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UNIFIED PROGRAM CONSOLIDATED FORMrc l01 UNDERGROUND STORAGE TANK �^ ` )f4l/c/ OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per LIST TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,111,IV,and IX elow) a3o ❑ I.NEW PERMIT ❑ 3.RENEWAL PERMIT �5.CHANGE OF INFORMA" El 6.TEMPORARY UST CLOSURE El 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL O L' DATE UST PERMANENTLY CLOSED'. 439e DATE EXISTING UST DISCOVERED: o I�f I. FACILITY INFORMATION FACILITY ID 9(Agency Use Only) BUSINESS NAUE(Same as FAC LITY NAME BA-Doing Business As) 2 Q 23 bob 3 BUSINESS SltlqDpb a! fa- 10J CI"I'Y ,( I04 tec ll.TANK DESCRIPTION TANK ID 432 TANK MAN UFACTURER 433 TANK CONFIGURATION: THISTANKIS 434 1 ^ 'Sf ASTAND-ALONE TANK �N U r4V A�+�� 2.ONE MACOMPARTMENTED UNIT. �/ ,v f6. �V Com lege one Ratefor each wm anmml in the wit. DATE LIST SYSTEM INSTALLED 435 TANK CAPACI Y ALLON�6 NUMBER OF COMPARTfv1ENTS IN THE UNIT 437 ID.TANK USE AND CONTENTS 11 TANK USE a.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ k.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Lacl.de,Used Oil) ❑ 5.EMERGENCY GENERA'T'OR FUEL[HSC§252815(G] ❑ 6.OUTER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify) 439. CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify) 440a NON-PETROL L'UM:❑ Z USED OIL ❑ 10.ETHANOL ❑ 11OTHERNON-PETROLEUM S ecif): 4406 IV. TANK CONSTRUCTION TYPEOF TANK ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 3.FIBERGLASS ❑ G INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Spceify): 444 SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER S eci'): 445a 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 ❑ 1.SINGLE-WALLED ❑2.DOABLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION I23 CCR§2636OR3)I 458 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGIFURBINE CONTAINMENT SUMP I'YPE ❑ 1.SINGLE WALT. ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMEN I' ❑ I S'IEIII. ❑ 4.FIBERGLASS C] 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464, 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 4640 VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464g) VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464, RISER PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 464,1 RISER SECONDARY CONTAINMENT ❑ 1.STEEI. ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451,1 VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3,NO DISPENSERS ❑ 90.NONE 469. CONSTRUCTION MATERIAL ❑ 1.STEEI- ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4691F VIII. CORROSION PROTECTION STFELCOMPONTNTPRO'IECTION ❑ 2.SACRII=ICIALANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this LST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full compliance with legal requirements. azo. APPLICANT SIGNATURE DATE APPLICANT NAME(print) ... APPLICANT TITLE 472. UPCF UST-B-112 Rev.(122007)