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• • 1( o UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK ll ( b OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per 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 LX below) 430 1.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: 430, DATE EXISTING UST DISCOVERED: 11--2-0 -OX 430b I. FACILITYINFORMATION FACILITY ID#(Agency Use Only) t BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) b n - 3 BUSINESS SITE ADDRESS / 103 CITY C./ IN H.TANK DESCRIPTION TANK fD# 432 TANK MANUFACTURER 433 AV CONFIGURATION: THIS TANK IS 434 //s �//�� / �.A STAND-ALONE TANK /{ H ©J(6�-6 ❑2.ONE IN A COMPARTMENTED UNIT. {{f Co lee one M.fora wm mmmt in theumt. DATE UST SYSTEM INSTALLED 435 TANK CAPACLTY IN GALLONS 436 NUMBER OF COMPARTMENTS M THE UNIT 437 O 111.T.ANK USE AND CONTENTS :c K'o SL ❑ ia.MOvR v ii1CLE'c UELi.NG LJ i'o.NIARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE %jNC4.I4AZARDOUS WASTE Mcluaa Used a0 ❑ 5.EMERGENCY GENERATOR FUEL[HSC§2530L5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 43% CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ IC.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 40. NON-PETROLEUM,Nr.USED OIL ❑ METHANOL ❑ 11.OTHER NON-PETROLEUM S cc 4406 IV. TANK CONSTRUCTION TYPE OF TANK .SINGLE WALL El 2-DOUBLE WALL 095.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 4w ❑ 7.STEEL'INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify), 444a SECONDARY CONTAINMENT ❑ L STEEL ❑3.FIBERGLASS [j6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER(Sp ): a45a I OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS LJ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452 ❑ 4.TANK MEETS REQUIREMENT'S FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION I.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ❑ L PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR j261503)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.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 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464 P1PINGITURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 46td VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 454e 464,1 VENT SECONDARY CONTAINMENT ❑ LSTEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 464B VR PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464g 46411 VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4&h 464h1 VENT PIPING TRANSITION SUMPTYPE "IL SINGLE WALL El 2.DOUBLE WALL 90.NONE 464i. RISER PRIMARY CONTAINMENT H1L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 464'1 RISER SECONDARY CONTAINMENT ❑ LSTEEL ❑ 4.FIBERGLASS ❑ IO.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 4Mk1 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET Q 3.STRIKER PLATFJBOTTOM PROTECTOR ❑ 4.CONTAINWENT SUMP 451a< VII.UNDER:DISPENSER CONTAINMENT(UDC) CONSTRUCTION'TYPE ❑ `WALL ❑ '_ -WALL ❑ 3.NO DISPENSERS C190.NONE 46% CONSTRUCTION MATERIAL ElL STEEL ❑ 4.FIBERGLASS ❑ I O.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b VIIL CORROSION PROTECTION STEEL COMPONENTPROTECTION ❑ 2.SACRIFICALANODE(S) ❑ CIMPRESSEDCURRENT 6.ISOLATION 449. 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. APPLICANT NAME(print) 471. APPLICANT TITLE ^T UPCF UST-B-1/2 Rev.(12/2007)