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01 1 �I ► J UNIFIED PROGRAM CONSOLIDATED FORMaaaa"aaaaaaaaaaaa to UNDERGROUND STORAGE TANK 1,101111 OPERATING PERMIT APPLICATION-TANK INFORMATION low Loon, UST) TYPE OF ACTION (Check one item only. Form UST pemo on closure m removal,complete only this section and Sections I,TI,II,1V,and X below) 4M ❑ L NEW PERMIT ❑ 3.R[:NEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE n 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4101 I DATE EXISTING UST DISCOVERED: 4M^ I. FACILITY INFORMATION FACILITYIT)#(Agency Use Only) _ U Q :-M'17 I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) � 3 M Fc R v� BUSINESS SITE ADDRESS��11 Ion ,p a}CMiTC A_110CITY VtN�tcf1 a IL TANK DESCRIPTION TANK ID# 431 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 ��c7S ISS CouT1AImAl EN T ❑01.ASTAND-ALONE TANK SoLVTtoN� NE IN A COMPARTMENTED UNIT. sews: mwe�c DATE UST SYSTEM INSTALL® CON a3s TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 431 III TANK USE AND CONTENTS TANK USE LK..MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 419 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(6,saia,Ueai D I) ❑ 5.EMERGENCY GENERATOR FUEL Cl6.OTHERGENERATORFUEL ❑ 95.UNKNOWN ❑ 99 OTHER S [HSC f252913(c)] CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ( L ): 439, ❑ EEL UNLEADED ❑ Ib.PREMIUM UNLEADED 440 9-T.-DIESEL ❑ 5 S.JET . FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL I] 9.OTHER PETROLEUM S N0. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 11.OTHER NON-PETROLEUMS 4496 IV. -TANKCONSTRUCTION. TYPE OF TANK U I.SINGLEWALL EK.DOUBLEWALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ I.STEEL .FIBERGLASS ❑ 6.INTERNAL BLADDER q44 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER S ): 944, SECONDARY CONTAINMENT 1.STEEL 1UJ!FBERGLASS ❑ 6.EXTERIORMEMBRANELINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNO ❑99.OTHER(Specify): NSe OVERFILL PREVENTION .AUDIBLE&VISUAL ALARMS WN ZLIFLOAT 3.FILL TUBE SHUT-0FFVALVE 431. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PROD WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION [31.SINGLE-WALLED DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE .PRESSURE ❑ 2. VIIY ❑3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR 1636(,3) 439 PRIMARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS 8.FLEXIBLE 10_= RIGID PLASTIC 469 ❑ 90.NONE ❑ 95.UNKNOWN 099.OTHER(Specily): 469, SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 964b ❑ 90.NONE C395.UNKNOWN ❑ 99.OTHER(Specify); 464c P@MNGlTIJIRBINE COMAINMEM SUMP TYPE ❑ LSINGLEWALL UBLE WALL ❑ 90.NONE 9644 VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS0 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Sp.*) 469e 469 l VENT SECONDARY CONTAINMENT El 1.STEEL 2'4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 4Hf VR PRIMARY CONTAINMENT 0 1.STEEL ff 4.FIBERGLASS ❑ 10.RIGID PLASTIC 4618 ❑ 90.NONE 99.OTHER(Spa*) 469s 464 I VR SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99,GTHER(Sperify) 464h /6961 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WAL 2.DOUBLE WALL 90.NONE 46Ii RISER PRIMARY CONTAINMENT 1.STEEL 4.FBERGLASS 10.RIGID PLASTIC HU 90.NONE 0 99.OTHER(Spcify) 464j 469'1 RISER SECONDARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464k 9MI,1 FILL COMPONENTS INSTALLED L SPILL BUCKET 3.STRIKER PLATF/BOTTOM PROTECFOR to 4.CONTAINMENT SUMP 431. VII.UNDER DISPENSER CONTAINMENT.(UDQ CONST RUCTION TYPE ❑ I.SINGLE WALL UBLE WALL ❑3.NO DISPENSERS ❑ 90.NONE 469, CONSTRUCTION MATERIAL ❑ 1.STEEL ERGLASS ❑ 10.RIGID PLASTIC 0 99.OTHER(S Ty) 469bc VUL CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 449. IX. APPLICANT SIGNATURE CERTIFICATION: 1 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. LIC SIGNA DATE ' 970. APPLICANT NAME(print)A h Q 4J�' APPLICANT TITLE 4P UPCF UST-B-1/2 V- Rev.(I2/2007)