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UNIFIED PROGRAM CONSOLIDATED FORM It <br /> UNDERGROUND STORAGE TANK ) v-1 <br /> OPERATING PERMIT APPLICATION-TANK INFO MA (One fo m Us / <br /> TYPE OF ACTION (Check one item only. For m UST penoaneot closme or removal,complete only this section and Secllno,I,II,III,IV,and r below) 43 [� <br /> ❑ 1.NEW PERMIT 3.RENEWAL PERMIT ❑ 5. GE OF INFORMATION <br /> 6.TEMPORARY UST CLOSURE .UST PERMANENT CLOSURE ON SITE .UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 4301 DATE EXISTING UST DISCOVERED: 4306 <br /> 1 --o <br /> I. FACII TTY INFORMATION <br /> FACILITY ID#(Agency Use Only) <br /> _ 1 <br /> SINESS N as AC l 'i AME DBA-Doi Business As) 3 <br /> fi e � , ° - 2b 52 e"Ve <br /> B41A S,$bit ADSS o� Im C Im <br /> t r ov r <br /> II.TANK DESCRIPTION <br /> TANK ID# 432 TANK MANUFACTURER 433 ,THANNKK CONFIGURATION:THIS TANK IS 434 <br /> L,3y `� �j�(/ IGr t.A STAND-ALONE TANK <br /> / �CJ V �1., O�'y) ❑2.ONE IN A COMPARTMENTED UNIT. <br /> DA US SYSTEM STALLED 435Com 'C O1° Rra6 vi 0iew6t <br /> INS TANK t�er IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 43] <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(Include Umd O10 ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)I <br /> ❑ 6.OTHER GENERATOR FUELU-55-UNKNOWN ❑ 99.OTHER (Specify): 43% <br /> CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 4w <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUMS a9oe <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUM S 4406 <br /> W. TANK CONSTRUCTION <br /> TYPE OF TANK 1.5INGLE WALL U 2,DOUBLE WALL ❑ 95.UNKNOWN ,143 <br /> PRIMARY CONTAINMENT �.STEEL ❑ 3.FIEERGLASS ❑ 6.INFERNAL BLADDER 44q <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER IS <br /> awa <br /> SECONDARY COMAINhIEM ❑ 1,STEEL ❑J.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7,JACKETED 445 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER 5 ): 445a <br /> OVERFILL PREVENTION 1.AUDIELE 8.VISUAL ALARMS 2.BALL FLOAT 3.FI,L TUBE SHUT-OFF VALVE 452. <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVER FILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑1.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER <br /> SYSTEM TYPE 460 <br /> ❑ L S I ESSURE ❑ 2.GRAVITY [13.8CO <br /> FLEXIBLE <br /> ZONAL SUCTION ❑ 4.SAFE SUCffON x3 CCR¢263NeX3A 458 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Spmify): 461 <br /> SECONDARY CONTAINME ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ I0.RIGID PLASTIC 4Mb <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c <br /> PIPING/TURBINE CONTAINMENT SUMPTYPE ❑ 1.SINGLE WALL U2.DOUBLE WALL ❑ 90.NONE qMd <br /> VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PD?E PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT 1.STEEL 4.1' 10.RIGID PLASTIC ❑ 90.NONE U W.OTHER(Specify) 46k <br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE (] 99.OTHER(Specify) 4964f <br /> VR PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGm PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464g <br /> VR SECONDARY CONTAM.., U 1.STEEL Lj 4.FIBERGLASS ❑ 10.RIGIDPLASTIC 1] 90.NONE ❑ 99.OTHER(Specify) 4641 <br /> VENT PIPING TRANSITION SUMP TYPE Fl 1.SINGLE WALL Z.DOUBLE WALL 90.NONE 96961 <br /> RISER PRIMARY CONTAINMENT4 L <br /> 1.STEEL . BW.. <br /> FERGU 10.RIGID PLASTIC U 90.NONE 0 99..OTHER(Specify) 464i <br /> RISER SECONDARY CONTAINMENT L1 I.STEEL in 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4641 <br /> FILL COMPONENTS INSTALLED U I.SPILL BUCKET 3.STROM PLAT-W11 W PROTECTOR Lj 4.CONTAINMENT SGMP4451Matc <br /> VII.UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑3.NO DISPENSERS ❑ 9D-,NONE 46% <br /> CONSTRUCTION MATERIAL ❑ L STEEL ❑ 4,FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99,UTHER(S ify) 469bc <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. <br /> UL APPLICANT SIGNATURE <br /> CERTIFICATION: I cc that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, <br /> and f com I ce ith I al re ufremeota. <br /> APPLICANT SIGNATU C ter� DATE 4M. <br /> �V1 Is/1.sv� <br /> APPLICANT NAME(print 4n. APPLICANT Tf[L1 E,�{{ 4R <br /> 14�` CSO 7 ^ C co <br /> A[!CI[rmr <br /> t✓Ne®Ir <br />