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• 4 UNIFIED PROGRAM CONSOLIDATED FORM RAGE TANK OPERATING PERMIT UNDERGROUND PPLICAT ON-TANK INFORMATION TYPE OF ACTION (Check one item Only. For n„UST (One form ❑ I.NEW PERMIT y PennenenI closure or removal,complete only this section end Sections 1,II,fll,IV,and IX below) 430 ❑ 6.TEMPORARY UST CLOSURE 3.RENEWAL PERMIT 7.UST PERMANENT CLOSURE ON SITE L 5.CHANGE OF INFORMATION 3 DATE UST PERMANENTLY CLOSED: 8.UST REMOVAL mo. DATEEXISTING UST DISCOVERED: I. FACII ITY FACILITY[D#(Agency Use Only) INFORMATION BUSINESS NAME(Same as FACILITY NAME or BA-Doing BQ 1 vei- BA usiness As)OvL?5l0 to BA ,o BUSINESS SITE ADD SS 3 103 CITY 'v 4ip IN �yJ TANK m a II.TANK DESCRIPTION 432 TANK MANUFACTURER 433 TANKCONFIGURATION: TRISTANRIS VIVA/A I✓ 1.A STAND-ALONE TANK 434 DATE USTSYSTEM STALLED 433 1/TI/f" M2'ONE INACOMPARTMENTEDUNI-T TANK CAP CITY IN GALLONS 436 e4`na` TOf wL in a Omit NUMBER OF COMPARTMENTS IN THE UNIT 437 TANK USE ❑ la.MOTOR VEHICLE FUELING M•TANK ISE.AND CONTENTS 133.CHEMICAL PRODUCT STORAGE 0 I b.MARINA FI/ELMG ❑ 6.OTHERGENERATOR FUEL 4.HAZARDOUS WASTE(4¢IW-on VaH O/ip Ic.AViATION FOELING 439 �C/� CONTENT'S PETROLEUM: ❑ Ia.REGULAR UNLEADED 95.UNKNOWN Alv 05.EMERGE(CY GGENERATOR FUEL[RSC§25281.5(c)j (] Ic.MIDGRADE UNLEADED Ii 99.OTHER ❑ 3.DIESEL ❑ 5.JET FUEL ❑ I b.PREMIUM UNLEADED 439. �- ❑ S.PETROLEUM BLEND FUEL 9.OTHER PETROLEUM LI 6'AVIATION GAS 440 NON-PETROLEUM:❑ 7,USED OIL S ai a ❑ I LOTH--NON- I): ETHANOL ON PETROLEUMS i TYPE of rANx W. TANKCONSTRUCTION a4ob PRIN[I CONTAINMENT L SINGLE WALL ❑ 2.DOUBLE WALL 95.UNKNOWN ❑ 1.STEEL 03.F ER SS ❑ 6.INTERNAL BLADDER ❑ 7.STEEL INTERNAL LINING SECONDARY CONTAINMENT ❑ 1.STEEL 95.UNKNOWN ❑ 99.OTHER 444 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER S 44ge OVERFII.L PREVENTION 11 90.NONE 95.UNKNOWN ❑ 7.JACKETED 1.AUDIBLE&VISUAL ALARMS 0 OTHER S ); 945 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMIF E VALVE NSa V. PRODUCT/WASTE PIPING CONSTRUCTION 4n PIPING CONSTRUCTION ❑1.SINGLE-WALLED SYSTEM TYPE ❑ L PRESSURE ❑2'DOUBLE-WALLED 199.OTHER PRIMARY CONTAINMENT ❑ I.STEEL ❑ 2.GRAVITY 1-13.CONVENTIONAL SUCTION 4460 ❑ 4.FIBERGLASS 11x37 S,FLEXIBLE .SAFE SUCTION 23 CCR¢2636(. 458 SECONDARY CONTAINMENT 0 90.NONE 95.UNKNOWN 0 9g,Orly S 10.RIGID PLgSTIC ❑ 1.STEEL ( pacify): 464 ❑ 90.NONE 4.FIBERGLASS ❑S.FLEXIBLE a64. PIPING/1'URBME CONTAINMENT SUMP TYPE F•95.UNKNOWN ❑ 99-OTHER(Specity): ❑ 10.RIGID PLASTIC 46gb ❑ I SINGLE WALL ❑ 2.DOUBLE WALL464c VI.DE ❑ 90.NONE 6qa VENT PRIMARY CONTAINMENT NT,VAPOR RECOVERY(VR):AND RISER/FII,L:PIPE PIPING CONSTRUCTION: 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC VENT SECONDARY CONTAINMENTIII .NONE 0 99.OTHER(Specify) q� L STEEL ❑ 4.FIBERGLAS$ ❑ I0.RIGID PLASTIC VR PRIMARY CONTAINMENT 90.NONE ❑ 99.OTHER(Specify) 464`1 ❑ 1.STEEL ❑ 4.FIBERGLASS 10.RIGH PLASTIC 90.NONE 99.OTHER(Spxity} 464 f VR SECONDARY CONTAMA�M 464Fl ❑ I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 464 a VENT PIPING TRANSITION SUMP TYPE 90.NONE 99.OTHER(Specify) RISER PRIMARY CONTAINMENT L SINGLE WALL 2.DOUBLE WALL 4646 1.STEEL 4.FIBERGLASS NO 464m 10.RIGID PLASTIC 90.NONE 99.OTHERS 4643. RISER SECONDARY CONTAINMENT' 1 STEEL 1 pacify) 464i 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHERS 4640 FILL COMPONENTS INSTALLED ( pacify) 464k I.SPILL BUCKET 3.STRIKER PLATFIBOTTOM PROTECTOR 4.CONTAINMENT SUMP `IMk1 VII.UNDER DISPENSER CONTAINMENT 451.c CONSTRUCTION TYPE -), CONSTRUCTION MATERIAL L SINGLE WALL ❑ 2,DOUBLE WALL I.STEEL ❑ 4.FIBERGLASS 3.NO DISPENSERS ❑ 9p,NONE 46% ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Spai ) VIII. CORROSION PROTECTION 46%, STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION D APPLICANT SIGNATURE and N ae. CERTIFICATION: I certify that this UST system is rompadble with the hazardons suhstaace atotcd and AP ICANT IGNATURE uirements. that the informatloo Provided herein V true,accurate, fuR com Bance with I el r DATE APP [CANT NAME Mt) 470. Q 471. ADPL CW,TJTLE v �{ Z. W�✓ 4n. UPCF UST-B-1/2 Rev.(IZ/2007)