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UNIFIED PROGRAM CONSOLIDATED FORM !epe � ha/UNDERGROUND STORAGE TANK ( COPERATING PERMIT APPLICATION-TANK INFORMATION(onr UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,III,IV,and LC below) 430 I.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4100 DATE EXISTING UST DISCOVERED: // p�7 v 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 BUSINESS NAME IS e as FACILITY NAME or DBA-Doing Business As) 3 S� 1j_AN bG: BUS SS SITE ADD SS l03 CITY 104 C33 4 II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 453 TANK CONFIGURATION:THIS TANK IS 434 /,,,�Atttt� X.A STAND-ALONE TANK 95175 ❑2.ONE IN A COh1PARTMENIED UNIT. Complete one inm foremh cam corm the wit. DATE UST SYSTEM INSTALLED 435 TANK CAP M GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 417 III.TANK USE AND CONTENTS T.4NvK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINAFUELING LJ Ic.AVIATION FUELING 4'v 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Ind.d;:Us,A O10 ❑ 5.EMERGENCY GENERATOR FUEL(FISC$25281.5(01 ❑ 6.OTHER GENERATORFUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 4390 CONTENTS PETROLEUM: ❑ 1a.REGULAR UNLEADED ❑ Ic.MIDGRADEUNLEADED ❑ Ib.PREMIUM UNLEADED dao - - ❑ 3.DIESEL ❑ S.YET FUEL ❑ 6.AVIATI0N GAS - - ❑ 8.PETROLEUM BLEND FUEL 9.OTHER PETROLEUM S .i ): Aga4Lxc ail49Oe NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ I L OTHER NON-PETROLEUM(S0ea1fV)7 4406 IV. TANK CONSTRUCTION TYPEOFTANKI.SINGLE WALL El 2.DOUBLE WALL 095.UNKNOWN 443 PRIMARY CONTAINMENT LSTEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 1. TE L' LINING ❑ 95.UNKNOWN [199.OTHER (specify): 444° SECONDARY CONTAINMENT ❑ LSTEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LNER 1] 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 4450 OVERFILL PREVENTION U (.AUDIBLE&VISUAL ALARMSU 2.BALL FLOAT El3.FILL TUBE SHUT-OFF VALVE 45'-. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT'/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑I.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER 440 SYSTEM TYPE ❑ L PRESSURE ❑ 2.GRAvrrY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION Ill CCR 52636W(3)1 458 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 064a SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4Nb ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): a64c PIPING(TURBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4&d VI.VENT,VAPOR RECOVERY ANDRISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT LSTEEL 4.FIBERGLASS IO.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4H; 464,1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 46ff 464R VR PRIMARY CONTAINMENT ❑ 1.STEEL Cl 4.FIBERGLASS ❑ l0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 446 B VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ to.RIGID-PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 4&h 464hl VENT PIPING TRANSITION SUMP TYPE ❑ LSINGLE WALL ❑ '.DOUBLE WALL [1 90.N0NE 464 RISER PRIMARY CONTAINMENT ❑ I.STEEL C] 1.FIBERGLASS U I0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464i 464'1 RISER SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS El 10.RIGID PLASTIC 90.NONE C1 99.OTHER(Specify) 41Ak 464k1 FILL COMPONENTS INSTALLED ❑ I.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451.-0 VIL UNDER_DISPENSERCONTAINMENT(UDC) CONSTRUCTION TYPE El 1. E WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPE.SEP.S ❑ 90.NONE 465' CONSTRUCTION MATERIAL ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 46960 VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANOD'c(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 44B 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. APPLICANT SIGNATURE DATE 470. APPLICANTNAME(prim) 471 1 APPLICANT TITLE 472. IJPCF UST-B-1/2 Rev.(1212007)