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M r UNIFIED PROGRAM CONSOLIDATED FORM O 121131 t0l J UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closum or removal,complete only this section and Sections L II,II,IV,and IX below) 430 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE 0 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: u0. DATE EXISTING USTDISCOVERED: 4306 I. FACILIT] INFORMATION FACILITY ID#(Agency Use Only) T-TT!:: - 1 BUSINESS NAMES e u FACILITY NAME mr DBA-Doin Business As) 3 71 / L BUSINES S DRES� It. 9 IU cTl'Y L! �S2- l04 F II.TANK DESCREMO✓NO TANK ID# A (n' 432 TANK MANUFACTURER 433 TTA1NKCONFIGURATION:THIS TANK IS 434 /^ l;J`- V p pt L A STAND-ALONE TANK �(/� J �/ e 9 � [12.ONE IN A COMPARTMENTED UNTO. � Ineem 61.6 eamthemuc DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNTO 437 III..TANK USE AND CONTENTS TANK USE Ia.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ CHAZARDOUS WASTE(16,1 eUu OTB ❑ S.EMERGENCY GENERATOR FUEL(HSC¢25281.5(c)I ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439. CONTENTS PETROLEUM: ❑ 1.REGULAR UNLEADED � Ic.MIDGRADE UNLEADED 0 Ib.PREMIUM UNLEADED 440 [3 3.DIESEL 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM: 7.USED Oe. ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUMS i 440b IV. TANKCONSTRUCTION TYPE OF TANK ❑ LSMGLE WALL 2.DOUBLE WALL 095.UNKNOWN 443 PRIMARY CONTAINMENT ❑ I.STEEL LZ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN [199.OTHER ($ ): 444+ SECONDARY CONTAINMENT ❑ L STEEL 3.FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE 8 95.UNKNOWN ❑99.OTHER(S ): Oh OVERFILL PREVENTION LAUDIBLE&VISUAL ALARMS 2.BALLFLOAT 3.FILL TUBE SHUT-OFF VALVE 453. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V..-PRODUCT`/WASTE PIPING CONSTRUCTION' P@ING CONSTRUCt[ON ❑1. GLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑1.CONVENTIONAL SUCTION ❑ SrSU R3 CCR¢26JNaX3)] 458 PRIMARY CONTAINMENT ❑ L STEEL IJTJ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGBJ PLASTIC 464 ❑ 911.NONE [] 95.UNKNOWN ❑ 99.0THER(Specify): 464+ SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER(Specify): 464c PIPINGrrURBINE CONTAINMENT SUMP TYPE I.SINGLE WALL ❑2.DOUBLE WALL ❑ 90.NONE 464d 'Vi:VENT,VAPOR RECOVERY:(�R).AND_RISER/FILL PD'E PIPING COPiSTRUCTION VENT PRIMARY CONTAINMENT I.STEEL W 4.FIBERGLASS 10.RIGID PLASTIC U 90.NONE U 99.OTHER(Specify) ab4e 46U1 VENT SECONDARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 19 90.NONE Q 99.OTHER(Speedy) 4%f 4Mft VR PRIMARY CONTAINMENT - I.STEEL K4.FIBERGLASS 0 10.RIGH)PLASTIC 0 90.NONE U 99.DIM(Specify) 4449 464.1 VR SECONDARY CONTAINMENT ❑ I,STEEL 4.FIBERGLASS 10.RIGIDPLASTIC 90.NONE U 99.OTHER(Specify) a61h 46 h1 VENT PIPING TRANSITION SUMP TYPE L SINGLE WALL Q 2.DOUBLE WALL JZ 90.NONE a64i. RISER PRIMARY CONTAINMENT US,1.STEEL U 4.FIBERGLASS U 10.RIGIDPLASTTC U 90.NONE U 99.OTHER(Specify) 46Ij 464'1 RISER SECONDARY CONTAINMENT EILSTEEL 4.FIBERGLASS 10.RIGIDPLASTIC 0 90.NONE 0 99.OTHER(Specify) 461k 4641 FILL COMPONENTS INSTALLED I.SPTLLBUCKET 01sTIUKERPLATIvEMOmPROTEcTOR J34.CONTAINMENT SUMP 451st VR.UNDERDISPENSER CONTAINtYIENT("o CONSTRUCTION TYPE ($.I.SINGLE WALL ❑ 2 DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ LSTEEL 5L 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(S i - 469bc VIR..CORROSION PROTECTION : STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑4.IMPRESSED CURRENT (3 6.ISOLATION 448. IX 'APPLICANT SIGNATURE CERTIFICATION:I certify that this UST system is compatible with the hersrdow substance stored and that the information provided herein U true,accurate, and 1n fuI Bance with legal quirements. APPLICANT SIGNATURE DATE 12 470. APPLICANT NAME(print) 471' APPLICANTTITLE I 4r_ DC�x-Pct' UPCF UST-B-1/2 Rev.(12/2007)