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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK Rx OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UsT) TYPE OF ACTION (Check m . For an UST pelmm,,em closure or removal,complete only this section and Sections I,Il,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 DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 S VC ON C�{r G)' vr7i2- BUS ESS SITE ADDRESS 103 CITY /✓)l9iV 7C--CI IW o W 7rC/)'l J F 19)/e II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 ❑ TAW 9 L-�x e 2.ONE INACOMPARTMENTED UNff. Ca a<one forwc6 Hain Newit DATE UST SYSTEM INST LED 435 TANK CAPACITY M GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 �� 3 000 C u III.TANK USE AND CONTENTS TANK USEla.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING LJ 1c.AVIATION FUELING 439 �3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Inda a Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC i25281.5(e)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 43% CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED 5ff4b.PREMIUM UNLEADED 490 ❑ J.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 490a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUMS i : 4406 IV. TANK CONSTRUCTION YN&4E K ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 AINMENT ❑ I.STEEL � FIBERGLASS ❑ 6.INTERNAL BLADDER444❑ 7.STEEL+IMERNALLMMG ❑ 95.UNKNOWN ❑ 99.OTHER (S CONTAINMENT ❑ 1.STEEL ,,meq<� FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED❑ 90.NONE I.J 95.UNKNOWN ❑99.OTHER(S xi ):EVENTION 1.ADDIBLE&VISUAL ALARMS 2.BALL FLOAT J.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVE ILL P VENTION EQUIPMENTV. PRODUCT/WASTE PIPING CONSTRUCTIONRUCTION ❑1.SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHERE LPRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION CCR J2636(a)(J) 458 PRIMARY CONTAINMENT ❑ 1.STEEL45-11-95, 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 469 1190.NONE ❑ 95.UNKNOWN ❑ 99.OTHER'Specify): 964a SECONDARY CONTAINMENT ❑ 1.STEEL MY,4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING,TURBINE CONTAINMENT SUMP TYPESINGLE WALL ❑ 2.DOUBLE WALL [190.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I.STEEL )KJ,4.FIBERGLASS ❑ 10.RIGw PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4s* 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC R,90.NONE ❑ 99.OTHER(Specify) 641 44 648 VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 4 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC $(90.NONE [199.OTHER(Spec)%) 464h 46461 VENT PIPING TRANSITION SUMP TYPE 0 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE RISER PRIMARY CONTAINMENT L STEEL [34.FIBERGLASS 10.RIGID PLASTIC 90.NONE C1 99.OTHER(Specify) 4641 464'1 RISER SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464E 464kl FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATEIBOTTOM PROTECTOR [14.CONTAINMENT SUMP 451st VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 46% CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS 10.RIGIDPLASTIC ❑ 99.OTHER(Specify) 469bc VIII. CORROSION PROTECTION E^ STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448' IX. APPLICANT SIGNATURE aa -j CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided 3tereih'Is true,accurate, and in fall cAmpliAnce with 1 al requirements. - APPLICANT SIGNATURE 5 DATE �Q Zq/�p 470.6> 4n. APPLICANT TITLE 4n. APPLICANT NAME(print � _ r U UPCF UST-B-1/2 Rev'(12/266'7)