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UNIFIED PROGRAM CONSOLIDATED FORM h UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one Foim!.pa t7S -�I i TYPE OF ACTION (Check one item only. Fo•en UST permanent closure"r oval,complete only this srection and Secfions I,II,III,[V,and IX below) 430 ❑ 1.NEW PERMIT M 3.RENEWAL PERMIT ❑_5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL;:;`..- DATE UST PERMANENTLY CLOSED: Q a (1 DATE EXISTING IIST DISCO Mm L FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESSNAME(SamenFACRiTYNAMEorDBA-DomgBusiness As) , BUSINESS SITE ADDRESS ^ l0; CITY 104 MTANKDESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANKCOTIRGURATION:TRISTANKIS7 43a ,/ / ❑I.ASTAND-ALONE TANK /�l 7 dnlK�✓DcJ.J ONE IN A COMPARTMENTED UMT. kte raw f%eachcae2tmtlm wit. LQ,y DATE UST SYSTEMIjIST.(1I,LED 435 TANK CAPACITY IN GALLONS 436 ER OF MPAR OnQQL(Unl t>< C ISI.TANK USE AND CONTENTS TANKUSE a'El MOTOR VEHICLE FUELING [I It.MARINA FUELING ❑ le,AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTEMdodecu oi0 ❑ 5.EMERGENCY GENERATOR FUEL NHw§25281.5(c)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99,OTHER(S ): 4390 CONTENTS PETROLEUM: ❑ I.REGULAR UNLEADED ❑ Ja MIDGRADELIM,F.ADID Ib.PREM)UMtINLEADED 4a6 17 .DIESEL ❑ 5.JEf FUEL ❑ 6.AVIATION GAS 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (S 44oa NON-PETROLEUM:❑ 7.USEDOI, ❑ 10.ETHANOL ❑ ILOTHERNON-PEIMOLEUM(Specifyjggpy IV. TANK CONSTRUCTION TYPE OF TANK ❑ L SINGLE WALL 2.DOUBLE WALL ❑95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 6.INTERNAL BLADDER 4q4 ❑ 7.STEEL+INTERNAL LINING. El 95.UNKNOWN El99.OTHER (S ): 444. SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER 5 ): 4a5a OVERFIILPREVENTION .AUDIBLE&VTSUALALARMS BALLFLOAT �3,FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEET'S REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENHON EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGI,&WALLED .DOURER-WALLED ❑99.OTHER 46p SYSMMTYPE 0ZLPRESSURE ❑ 2.GRAVTIY ❑3.00NVENT[ONALSUCTION ❑ 4.SAFE SUCTION(z3 §2636(.X3)1 450 PRIMARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 8.F1.EIaBLE ❑ IO.EGIDPLASTIC 46a ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Slecify): 46aa SECONDARY CONTAINMENT ❑ I.STEEL .FIBERGLASS ❑ e.FLMBLE ❑ 10.E01DPLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specity): 464c PIPINC'IURBINE CONTAINMENT SUMP TYPE 01-SNULE WALL DOUBLE WALL 090.NONE 464d VL VENT,VAPOR RECOVERY(VR)AN6 RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARYCONTAINMENT ❑ L STEEL A'I-.FIBERGLASS ❑ l0.RIGID PLASTIC ❑ 90.NONE ❑ 99,OTHER(Specify) 464e a6ae1 VENT SECONDARY CONTAINMENT ❑ 1.MEL .EBERGI,ASS ❑ 10.RIGID PLASTIC ❑ 9D.NONE (] 99.OTHER(Specify) 464r 46 fl VR PRIMARY COINTA]NMFN'I' ❑ i.STEEL ,FIBERGLASS ❑ ]0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OT11E1(Specify) 4648 VR SECONDARYCONTAINMENT ❑ 1.STEEL CRFIBERGLASS ❑ IO.RIGID PfASITC ❑ 9D.NOPIE ❑ 99.0'TERR(Spemfy) 464E VENTPIPAIG TRANS1170N SUMP TYPE ❑ I.SINGLE WALL DOUBLEArAI I. ❑ 90_Mpp1E y�i. RISER PRIMARY CONTAINMENT ❑ 1.STEEL FIBERGLASS ❑ I0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OT[IER(Spea[y) 46.1 4641 RISER SECONDARY CONTAINMENT ❑ 1.STEEL .EBERGLASS ❑ 10.RIGID PLASTIC ❑ 9D.NONE ❑ 99.OTHER(Specify) 464k 464tH FILL COMPONENTS INSTALLED -LE.L.SPILL BUCKET ❑ 3.STRRERPLATF/BOTTOM PROTECTOR ❑ 4.COMAINhRMSUMP 451o.c VIL UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ I.SINGLE WALL2.DOUBLE WALL 113.NO DISPENSERS ❑ 90.NONE 469, CONSTRUCTION MATERIAL ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(S ify) 4696c VUL CORROSION PROTECTION STEEL COMPONENT PROTECTION 2 SACRIFICIAL ANODES) ❑4,IMPRESSED CURRENT ❑ 6.ISOLATION aae. DL APPLICANT SIGNATURE CERTMCATION:I certify that this USC system is compatible with the hantdous substance alotsd and tlmt the iuformafion provided berein Is true,aecurate, and in full cem ce with al re uirements. PUC=GNATU TE i / azo. APPLIC NAME(print) rean. APPLICANT TITLE `' UPCFUST-B-In Rev.(12/20117)