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Ls- A? ( ' it UNIFIED PROGRAM SOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one them Ise,UST) TYPE OF ACTION (Check ane item 0101Y. For an UST permanent closure or removal,complete only this I.NEW PERMIT El 3.RENEWAL PERMIT section and Sections;1, IDIV,I , ,and IX below) 430 ❑ $ 6.TEMPORARY UST CLOSURE T UST PERMANENT CLOSURE )N SITE 5.CHANGE OF INFORMATION 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 4106 I. FACIIITY INFORMATION FACII,ITY ID#(Agency Use Only) ) I c - 7 .� BUSINESS NAME(Same as FACILITY NAME m DBA-Do' Bmtaem As) 3 � l( u BUSINESS D ADRESS 2 M .d 1 1/lV. IL TANK DESCRrEMION TANKID# n 432 TA�NKfMANpU_F,ACTURER 433 + -yCONFIGURATION: THISTANK 0 434 IJ LyJ�V 1 N F� A STAND-ALONE TANK 1 !/ IN A COMPARTMENTED UNIT. DATE UST SYS INT US °cone ror�' °'meivuc TANK CAPACIT J[{GALLONS 4 NUMBER OF COMPARTMENTS IN THE UNIT 437 IIL TANK USE AND CONTENTS' TANK USE la.MOTOR V`cMULE FUELING I] It.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.0 PRODUCTSTORAGE ❑ 4.HAZARDOUS WASTE(y JWo Dem qO 0 5.EMERGENCY GENERATOR FUELI HSC 232e L3(c)] ❑ 6.OTHER GENERATOR FUEL E395.UNKNOWN ❑ 99 OTHER IS i ): E 43% CONTENTS PETROLEUM: ❑ le.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED Ib.PREMIUM UNLEADED 49a ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 41h NOMPETROLEUM:(] ].USED OIL ❑ 10.ETHANOL LI I I.OTHER NON-PETROLEUM S 4496 IV. TANK_CONSTRUCTION TYPE OF TANK ❑ I.SINGLEWALL 2 DOUBLE WALL ❑ 95.UNKNOWN M3 PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 411 ❑ 7.STEEL I JNTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S 44y SECONDARY CONTAINMENT ❑ 1.STEQ. .FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LR ❑ 7.OVERFILL JACKETED 443 ❑ 90.NONE Q 95.UNKNOWN ❑99.OTHER(S ); N3i OVERFIPREVENTION I.AUDIBLE&VISUALALARMS ALL FLOAT 3.FILL TUBE SHUTAFF VALVE 432 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER �g SYSTEM TYPE I.PRESSURE .❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.$qFE SUCTION 23 CCR 2636( 3) 438 PRNIARY CONTAINMENT ❑ 1.STEEL J:1-4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGm PLASTIC 468 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): �y SECONDARY CONTAAIMENT 1.STEEL .FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4616 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): qgk PIPING/TURBINE CONTAINMENT SUMP TYPE I] 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 4646 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FML PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 I.STEEL _Q-A.FIBERGLASS 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 464e VEIN SECONDARY CONTAINMENT 11 L STEEL fY4.FEBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 469f VR PRIMARY CONTAINMENT El I.STEEL 4.FIBERGLASS4�g ❑ 10.RIGm PLASTIC 90.NONE 99.OTHER(Specify) 961g VR SECONDARY I U L STEEL 4.FIBERGLASS 10.RIGm PLASTIC 1 ❑ W.NONE 99.OTHER(Sp-,y) 46iM1 VENT PIPING TRANSITION SUMP TYPE I.SINGLE WALL 2.DOUBLE WALL 0 90.NONE 4N61 46 i RL$F2l PRIMARY CONTAI4h¢NT UH1.STEEL 4.FIBERGLASS ffU 10.RICm PLASTIC D 90.NONE 0 99.OTHER(Speti{y) qby RISER SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGm PLASTIC 90.NONE 99.OTHER(Specify) 4NI FlLL COMPONENTS INSTALLEDU 1.SPILL BUCKET Lj 3.STRIKER PLATE/BOT TOM PROTECTOR 0 4.CONTAINMENT SfIMP 4546x1 VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ L SINGLE WALL .DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469+ CONSTRUCTION MATE3UALQ 1.STEEL ur 4.FIBERGLASS ❑ 10.MUM PLASTIC ❑ 99.OTHER(Specify) 4696c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.MPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I ce that this UST system is compatible with the hanrdous substance stored and that the Information provided herein is true,accunte, said fnllro ith il uiremenb. APPLICANT SIGNATU C/ DATE !)/ /h D r aro APPLICANT NAME(prinQ Iv 4II. APPLICANTTIT[E 6M 4n. UPCF UST-B-1/2 �IQiT\ Rev.(12/2007)