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i <br /> j.W TIED PROGRAM CONSOLIDATED FOIftj <br /> UNDERGROUND STORAGE TANK s ( 3/67 <br /> OPERATING PERMIT APPLICATION -TANK INFORMATION (One form per UST) <br /> TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,It,171,IF,and IX below) 430. <br /> ❑ 1.NEW PERMIT 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE ❑ S.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430. 1 DATE EXISTING UST DISCOVERED: 4306 <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) _ _ L <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3 <br /> -MBUSINE SSITEADDkUJSS 103, 1 CITY Im. <br /> a <br /> II. TANK DESCRIPTION <br /> TANK ID# 432. TANK MANUFACTURER 433, TANK CONFIGURATION:THIS TANK IS 434, <br /> 1.ASTAND-ALONE TANK Complete one page for each <br /> OOC OI-1 %5433 qwtt%5 Izartit 2.ONE M A COMPARTMENTED UNIT compazmat In We ma. <br /> DATE UST SYSTEM INSTALLED 435. 1 TANK CAPACITY IN GAMS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437 <br /> VQ.cs0c I <br /> III. TANK USE AND CONTENTS <br /> TANK USE aq� la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ir.AVIATION FUELING 439, <br /> IJ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes UsW UO ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN 0 99.OTHER(Specify): 439. <br /> CONTENTS PETROLEUM: 0 la.REGULAR UNLEADED 0 Ic.MIDGRADE UNLEADED 0 Ib.PREMIUM UNLEADED 440. <br /> 3.DIESEL 0 5.JET FUEL E36.AVIATION GAS <br /> 9.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440. <br /> NON-PETROLEUM: 7.USED OIL ❑ 10.ETHANOL- <br /> ❑ 11.OTHER NON-PETROLEUM(Specify): 4406. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK 0 1.SINGLE WALL2.DOUBLE WALL ❑ 95.UNKNOWN 443, <br /> PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 4a4. <br /> 0 7.STEEL+INTERNAL LINING 0 95.UNKNOWN 0 99.OTHER(Specify): <br /> SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS 0 6.EXTERIOR MEMBRANE LINER 0 7.JACKETED aas. <br /> 090.NONE 95.UNKNOWN 099.OTHER(Specify): 445. <br /> OVERFILL PREVENTION I.AUDIBLE&VISUAL ALARMS 0 2.BALL FLOAT a 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 Up I. 12SINGLE WALL 2.DOUBLE WALL [I99.OTHER 460. <br /> SYSTEM TYPE ..... 1 PRESSURE ❑ 2 GRAVITY 0 3.CONVENTIONAL SUCTION 0 4.SAFE SUCTION[23 CCR§2636(aN3)] 458. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL W 4.FIBERGLASS 0 8.FLEXIBLE 0 10.RIGID PLASTIC 464. <br /> ❑ 90.NON[ U 95.UNKNOWN ❑ 99.OTHER(Specify): 464. <br /> SECONDARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS ❑ &FLEXIBLE 0 10,RIGID PLASTIC 464b, <br /> 0 90.N N 95.UNKNOWN ❑ 99.OTHER(Specify): 464e <br /> PIPINGITURBINE CONTAINMENT SUMP TYPE X I SINGLE WALL 0 2.DOUBLE WALL 0 90.NONE -- 4644 <br /> VI. VENT,VAPOR RECOVERY (VR) AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT _� I tillllll. U 4.FIBERGLASS El 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify): 46646 <br /> VENT SECONDARY CONTAINMENT ❑ i till-.Ill. ❑ 3 11131 RGLASS ❑ 10.RIGID PLASTIC JJQ 90.NONE ❑ 99.OTHER(Specify): 46644f1 <br /> VR PRIMARY CONTAINMENT I.STEEL ❑ 4 FIBERGLASS ❑ IO.RIGIDPLASTIC N90.NONE 0 99.OTHER(Specify): 464g' <br /> h. <br /> VR SECONDARY CONTAINMENT [11.STEEL [1 4.FIBERGI ASS U 10.RIGID PLASTIC X90.NONE [I99.OTHER(Specify): 464hL <br /> . .... 4641. <br /> VENT PIPING TRANSITION SUMP TYPE _ -L SINGLL WAI.1. U 2.DOUBLE WALL ❑ 90.NONE <br /> RISER PRIMARY CONTAINMENT p 1.STEEL 0 4.FIBERGLASS U 10_RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify)- 464 j, <br /> RISER SECONDARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS U I0.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify): 460k1 <br /> FILL COMPONENTS INSTALLED 1.SPILL BUCKET ❑ 3.STRIKP.R PLA IF 130TTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a, <br /> VII. UNDER DISPENSER CONTAINMENT (UDC) <br /> CONSTRUCTION TYPE ji�1 SINGLE WALLQ_2 [30UBLEWALL 03.NO DISPENSERS 0_90.NONE 469a. <br /> CONSTRUCTION MATERIAL ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 99.OTHER(Specify) 469b. <br /> f>� a69c. <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 0 6.ISOLATION 448- <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information prof is true, <br /> accurate,and in full compliance with legal requirements. <br /> A <br /> APPLICANT SIGNATURE DATE 420' <br /> - - d <br /> APPLICANT NAME(print) u - aU 421' APPLICANT TITLE 422 <br /> r <br /> UPCF UST-B Rev.(12/2007)-1/2 www.tnfldocs.org <br />