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i w4FIED PROGRAM CONSOLIDATED FOhwi <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION -TANK INFORMATION (one fmtnp- <br /> TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11,111,IV,and LY below) 430. <br /> ❑ I.NEW PERMIT 3.RENEWAL PERMIT [j5.CHANGE OF INFORMATION <br /> El 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430a. 1 DATE EXISTING UST DISCOVERED: 4306, <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) .3 C `% / _ 1' <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> IP t cz <br /> BUSINESS SITE ADD ESS 103. CITY IN. <br /> II. TANK DESCRIPTION <br /> TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. <br /> 1.A STAND-ALONE TANK Complueonepaecformh <br /> It 9 OI 7 '*1-- 435. <br /> O W CN O 2.ONE IN A COMPARTMENTED UNIT wmpaM-t We on11. <br /> DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLO 436. NUMBER OF COMPARTMENTS IN THE UNIT 432. <br /> fo 'to •�l � ooe <br /> III. TANK USE AND CONTENTS <br /> TANK USE la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439. <br /> 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE Raduaea Used aO ❑ 5.EMERGENCY GENERATOR FUEL[HSC§2528L5(c)] <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a. <br /> CONTENT'S PETROLEUM: la REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ I b.PREMIUM UNLEADED 440. <br /> N 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440a <br /> NON-PETROLEUM:(] 7.USED OIL ❑ 10.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443, <br /> PRIMARY CONTAINMENT ❑ L STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 400 <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444a. <br /> SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. <br /> 090.NONE 95.UNKNOWN ❑99.OTHER(Specify): 445a. <br /> OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ,I% 3.FILL TUBE SHUT-OFF VALVE 452. <br /> 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 99.OTHER 460. <br /> SYSTEM TYPE1.PRESSURE _ ❑ 2 GRAVITY _ _._ ❑ 3 CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION X23 CCR§2636(a)(3)] _ 458. <br /> PRIMARY CONTAINMENT N1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 404+ <br /> SECONDARY CONTAINMENT ❑ 1.STEEL Q 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. <br /> ❑ 90.NONE ❑ 95.IJNKNOW4 ❑ 99.OTHER(Specify): 464c <br /> PIPINGITURBINE CONTAINMENT SUMP TYPE IR 1 SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644. <br /> VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4464 <br /> VENT SECONDARY CONTAINMENT ❑ I STEEL ❑ 4.FIBERGLASS ❑ 10 RIGID PLASTIC P% 90.NONE ❑ 99.OTHER(Specify): 4464L <br /> VR PRIMARY CONTAINMENT $ L STEEL ❑ 4.FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 4MI, <br /> VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE i. <br /> RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4:2 <br /> RISER SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC pa 90.NONE ❑ 99.OTHER(Specify): a� <br /> FILL COMPONENTS INSTALLED PQ 1.SPILL BUCKET ❑ 3.STRIKER PLATOBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451 a-c. <br /> VII. UNDER DISPENSER CONTAINMENT (UDC) <br /> CONSTRUCTION TYPE X 1 SINGLE WALL ❑ 2 DOUBLE WALL Q_.3 NO DISPENSERS ❑ 90 NONE' 469a <br /> -_._ ._..-.-.- -" _-. -._.__.__ ____-_- <br /> CONSTRUCTION MATERIAL ❑ 1 STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99 OTHER(Specify) 4696. <br /> 469c <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, <br /> accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 420. <br /> - V9 <br /> APPLICANT NAME(print) 21' APPLICANT TITLE w --�..,/ 422. <br /> UPCF UST-8 Rev.(12/2007)-1/2 www.unidocs.org <br />