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�`AJVE® Ur .00,I UNIFIED PROGRAM CONSOLIDATED FORM FIV UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION( NWRQ C TYPE OF ACTION (Check one item only. For on UST permanent closure or removal,complete only this section and Sections I,II,III,IV,anQ77]Cl{'9 sa1�'r M ENT 6r1 ❑ 1.NEW PERMIT 173.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATI�f�^� f1 �'VV�'L � L ❑ 6.TEMPORARY UST CLOSURE [r 7. S/T�PERMANENT CLOSURE ON SITE S.UST REMOVAL � 7 4306 DATE UST PERMANENTLY CLOSED: RIJ EP 4304 DATE EXISTING UST DISCOVERED: AM I. FACILITY INFORMATION FACILITY ID p(Agency Use Only) - - �' �! 1 AV BUSINESS NAME(Same as FAC TTY NAME or DBA-Doing Busiress As) 3 BUSINESS SITE rt S .1 l03 CITY 104 N / II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434- < < �/(� CAfT .A STAND-ALONE TANK AD(.� [12.ONH IN A COMPARTMENTED ES2UNIT. Couplet:we Jose nor each in the IT.tamt. DATE UST SYSTEM T 1,gp 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMP NTS IN THE UNIT 437 p oO0 �✓� III.TANK USE AND CONTENTS S✓l TANK USE Ella.MOTOR VEHICLE FUELING [31b.MARINA FUELING [I lc.AVIATION FUELING 439 O� ❑ .CHEMICAL PRODUCT STORAGE [14.HAZARDOUS WASTE(IneWdes Used Oil) [15.EMERGENCY GENERATOR FUEL[HSC§2528L5(c)l 6.OTHER GENERATOR FUEL [195.UNKNOWN ❑ MOTHER (Specify): 4394 yk > CONTENTS PETROLEUM: ElIa.REGULAR UNLEADED [31c.MIDGRADE UNLEADED [Ilb.PREMIUM UNLEADED 400 /v DIESEL [15.JET FUEL El 6.AVIATION GAS �] 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 4406 /4 El11.OTHER NON-PETROLEUM(S eci : T-1V IV. TANK CONSTRUCTION ` TYPE OF TANK 1.SINGLE WALL [32.DOUBLE WALL ❑ 95.UNKNOWN 443 �\ PRIMARY CONTAINMENT ❑ L STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 C ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ MOTHER (Specify: 4444 SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 -90.NONE ❑ 95.UNKNOWN ❑99.OTHER S ecif : 4454 OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS K2.BALLFLOAT 3.FILL TUBE SHUTOFF VALVE 452 El 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION tKI.SINGLE-WALLED El 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ z.GRAVITY3.CONVENTIONAL SUCTION [14.SAFE SUCTION In CCR§2636(.X3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL LI4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464° SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b EC90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify)- 464` PIPINGlIURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 4e 90.NONE 4Md VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464. 464e1 VENT SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTICO.NONE ❑ 99.OTHER(Specify) 4642 4NII VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS [1 10.RIGID PLASTIC0.NONE 1] 99.OTHER(Specify) 4643 M 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0.NONE ❑ 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL �0.NONE 4Mi. RISER PRIMARY CONTAINMENT jefq STEEL ❑ 4.FIBERGLASS ❑ I O.RIGIDPLAb IIC ❑ 90.NONE ❑ 99.VIHER(Spccify) 4641 4MIJ RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 'SJO.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED ❑ 1.SPILLBUCKET 3.STRIKERPLATFJBOTTOMPROTEClUK ❑ 4.CONTAINMENT SUMP 451a, VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ I.SINGLE W ALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS 90.NONE 469. CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 99.OTHER(Specify) /tf 4696` VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION /1/da 448' IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full compliance with legal requirements. 470 PLICANT SIGNATU DATE APPLICANT NAME(print) 471. APPLICANTTITLE' an. J-1 I - L �f L�v'r Jul GZ UPCF UST-B-1/2 Rev.(12/2007)