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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per u9T) 1 TYPE OF ACITON (Check one item only. For an UST permanent closure or removal,complete ooly this section and Sections I,ll,III,IV,and IX 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 hU )`- DATE UST PERMANENTLY CLOSED: 430. DATE EXISTING UST DISCOVERED: 4306 I. FACIIITY INFORMATION FACILITY H)#(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) J Gi✓ BUSINESS SITE ADDRESS 101 CITY 104 II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 (.ONE IN ALONE COMPARTMENTED (.ONE IIY A COMPARTMENTED UNR. C4iftone 6 mh in eual. DATE UST SYSTEM INSTALLED 435 T CAPACITY IN GALLONS 430 NUMBER OF COMPARTMENTS INTIB?UNIT 437 III.TANK USE AND CONTENTS TANK USE 5 la MOTOR VEHICLE FUELING E3Ib.MARINA FUELING E3 le.AVIATION FUELING 439 []3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(heiudo Uw4 Oi) ❑ 5.EMERGENCY GENERATOR FUEL[HSC 425281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN - ): 43% CONTENTS PETROLEUM: [3 la.REGULAR UNLEADED ❑ la MIDGRADE UNLEADED Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL 13S.JET FUEL E36.AVIATION GAS (38.PETROLEUM BLEND FUEL El9.OTHER PETROLEUM (Specify): 4a9a NON-PETROLEUM:[3 7.USED OI. ❑ 10.ETHANOL 11.OTHER NON-PETROLEUMS 4406 W. TANK CONSTRUCTION TYPEOFTANK ❑ I.SINGLE WALL 2.DOUBLE WALL 95.UNKNOWN 443 PR04ARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS LI 6.INTERNAL BLADDER aa4 ❑ 7.STEEL+INTERNAL LINING ❑ 93.UNKNOWN ❑ 99.OTHER S ): aa4. SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LMER ❑ 7.JACKETED 445 ❑ 90.NONE 95.UNKNOWN ❑99.OTHER(Specify): µ1 OVERFILL PREVENTION U I.AUDIBLE&VISUAL ALARMS 2.BALLFLOAT 3.FILL TUBE SHUT-0FF VALVE 452 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFI,L PREVENTION EQUB'MENT V. PRODUCT!WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED 2.DOUBLE-WALLED ❑99 OTHER 469 SYSTEM TYPE I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION 0SAFE SUCTION 23 CCR 2636(.X3)) 458 PRIMARY CONTAINMENT ❑ L STEEL 54 4.FIBERGLASS ❑ 8.FLEXIBLE 10.RIGID PLASTIC 464 ❑ 90.NONE El95.UNKNOWN ❑ 99.OTHER(Specify): 464. SECONDARY CONTAINMENT ❑ 1.STEEL 0 4.F03ERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Sp%*): 464c PIPING)TURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 4696 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRB4ARY CONTAINMENT 0 (.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 99-OTHER(Spw*) 464 4641 VENT SECONDARY CONTAINMENTEl 1.STEEL ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC 5p 90.NONE 99.OTHER(Specify) 464f 46 R VR PRIMARY CONTAINMENT1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 0 90.NONE [3-99.-OTHER(Specify) 464g 46 1 VR SECONDARY CONTAINMENTLl 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464h VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 464hl 2.DOUBLE WALL 90.NONE IML RISER PRIMARY CONTAINMENT Ww L STEEL U 4.FIBERGLASS U 10.RIGID PLASTIC R 90.NONE 99.OTHER(Specify) 464i 46'1 RISER SECONDARY CONTAINMENTLl 1.STEEL 4.FIBERGLASS l0.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 464k 46/kl FILL COMPONENTS INSTALLEDKILSPILLBUCKET 3.STRIKER PLATEIBOTTOM PROTECTOR M 4.CONTAINMENT SUMP 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 91,L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469+ CONSTRUCTION MATERIAL ❑ 1.STEEL 12 1.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES) Cl 4.IMPRESSED CURRENT Ck 6.ISOLATION 448. UL APPLICANT SIGNATURE CERTIFICATION: 1 certify that tiW ST system is compatible with the hazardous subsume shored and that the information provided herein is true,ace44rate, amt In fun arce with W requirements. APPLICANT SIG -� DATE 4m. APPLICANT Nr(prmt) 471. APPLICANT TITLE Owiz/�AZ 4n. UPCF UST-B-112 Rev.(I2/2007)