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! 0 (�M"' ?)Li UNIFIED PROGRAMCONSOLIDATEDFORMUNDERGROUND STORAGE TANKOPERATING PERMIT APPLICATION-TANK INFORMATIO (One form UST)TYPEOFACTION (Check one item only. Foran UST permanent closure or removal,complete only this section and Sections 1,II,HI,IV,and IX below) ❑ L 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: 431 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) I BUSWf SS NAME(Same as FAC TY NAME or DBA-Doing Biness As) 3 I.S � 7" y� BUSINE 0 IT__ (ADD Im CITY (TU IL TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 [12.ONE IN A COMPARTMENTED MT. CP . T T LE�1,p 435 TANK CAP CITY I�,SALLONS 4>6 NUMBER OF COMPARTMENTS IN TFIF UNIT 432 It)l "L III.TT UANKK USE AND CONTENTS TANK USEIa.MOTOR VEHICLE FITELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 C] 3.CHEMICAL PRODUCT STORAGE [14.HAZARDOUS WASTE(6 Isxiea Uad Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HK§252g1.5(c)] [16.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 43% CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMNM UNLEADED 440 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS &PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S ci : 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTI'IER NON-PETROLEUM(Specify): 449b MilTYPE OF TANK ❑ 1.SINGLE WAL 2.DOUBLE WALL Ll 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERTIAKL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 4Ma SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE 9 95.UNKNOWN ❑99.OTHER(Specify) 445a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS F R EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑I.SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ .GRAVITY ❑ 3.CONVENTIONAL SUCTION Ll4.SAFE SUCTION[23 CCR§26360)(3)] 458 PRIMARY CONTAINMENT I.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ' ❑ IO.RIGID PLASTIC 464 ❑ 90.NONE 0 95.UNKNOWN ❑ 99.OTHER(Spccify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL q 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Speeify): 404' PIPINGrrURBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 Vi.VENT,VAPOR RECOVERY(VR)AND RISER I FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS 10.RIGID PLASTIC Ef 90.NONE 0 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL fR 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 7nC 464n VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464g 46 I VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC V, 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL CK 90.NONE 4Me. RISER PRIMARY CONTAINMENT 1.STEEL LJ4.FIBERGLASS [110.RIGID PLASTIC U 90.NONE U 99.OTHER(Specify) 4611 ok 4641 RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS D 10.RIGID PLASTIC N 90.NONE 0 99.OTHER(Specify) 464k 464kl FILL COMPONENTS INSTALLED I.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451as VD.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE L SINGLE WALL 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ I.STEEL X 4.FIBERGLASS u i0.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bc VTII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIALANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION a48. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible wi the hazardous substance stored and that the information provided herein is true,accurate, and in full"AiliaW with legal req%lialement APPLICANT SIGNATU DATE 470, APPLICANT NAME(print) aa�g.2,r / �� m rl O�21' APPLICANT TITLE iy-r,M.,rt`�� 472. U9.4-040 Ar UPCF UST-B-1/2 Rev.(12/2007)