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UPCF UST -B-1/2 Rev. (12/2007) UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (one form per UST) TYPE OF ACTION (Check om He. only. Fm an UST permanent closure m removal, complete only this section and Sections I, II, III, IV, and IX below) 430 ❑ 1. NEW PERMIT ❑ 3. RENEWAL PERMIT5. CHANGE OF INFORMA 6. TEMPORARY UST CLOSURE [I7. UST PERMANENT CLOSURE ON SITE S. UST REMOVAL DATE UST PERMANENTLY CLOSED: 43011 DATE EXISTING UST DISCOVERED: ° L FACILITY INFORMATION FACILITY m # (Agency Use Only) 1-11 1 1-11 TTT BUSINESS NAME (Sax as FACILITY NAME or DBA-Doing Business As) 3 BUSINESS SITE DRESS Ian CITY IoM I. TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 ALONE ANK 2.ONE � �� TME IN COMPARTMENTED ❑ Z. ONE M A COMPARTMENTED INR. 0 1�\ C ac oro fmaa in tlsuar. DATE UST SYSTEM INSTALLED 635 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 III. TANK USE AND CONTENTS TANK USE Ia. MOTOR VEHICLE FUELING ❑ Ib. MARINA FUELING ❑ Ic.AVIATIONFUELING 039 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE(6duda Uae6O0) ❑ 5. EMERGENCY GENERATOR FUEL past 125281.5(c)) ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ W. OTHER (Specify): 43% CONTENTS PETROLEUM: ❑ Ia. REGULAR UNLEADED ❑ Ic. MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 .$3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ S. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM S 441d NON-PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ILOTHERNON-PETROLEUMS i : 4406 W. TANK CONSTRUCTION TYPE OF TANK 1. SINGLE WALL DOUBLE WALL [3 95 UNKNOWN 443 PRIMARY CONTAINMENT STEEL STEEL 3. FIBERGLASS ❑ 6. INFERNAL BLADDER 444 7. STEEL t INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify):444 SECONDARY CONTAIM EMT ❑ 1. STEEL ❑ 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445 ❑ 90. NONE ❑ 95. UNKNOWN 99.OTHER (S ): rF-Q W. OVERFILL PREVENTION (.AUDIBLE A VISUAL ALARMS 0 2. BALL FLOAT 3K 3. FILL TUBE SHUT-OFF VALVE 452. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/ WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1. SINGLE-WALLED tik2. DOUBLE-WALLED [199. OTHER 460 SYSTEM TYPE . PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION 23 CCR 82636(aR3) 458 PRIMARY CONTAINMENT 1. STEEL . FIBERGLASS ❑ S. FLEXIBLE 10. RIGH) PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER(Specify): 464 SECONDARY CONTAINMENT 0 1. STEEL -Q'4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 4Nb ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 46k PIPINGfrURBTNE CONTAINMENT SUMP TYPE ❑ 1. SINGLE WALL U 2. DOABLE WALL El 90. NONE 4616 VI. VENT, VAPOR RECOVERY (VR) AND RISER/ FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT L1 (.STEEL A 4. FIBERGLASS 0 10. RIGID PLASTIC 0 90. NONE 0 99. OTHER (Specify) 464 4641 VENT SECONDARY CONTAINMENT 1. STEEL 4. FIBERGLASS 10. RIGID PLASTIC . NONE 99. OTHER (Specify) 464f 464n VR PRIMARY CONTAINMENT L STEEL 13 4. FIBERGLASS 10. RIGID PLASTIC 90. NONE 0 W. OTHER (Specify) 4648 464 1 VR SECONDARY CONTAINMENT ❑ 1. STEEL 0 4. FIBERGLASS Q 10. RIGID PLASTIC 90. NONE El 99. OTHER (Specify) 46Th 16h1 VENT PIPING TRANSITION SUMP TYPE 1. SINGLE WALL 2. DOUBLE WALL ja 90. NONE 4641. HU RISER PRIMARY CONTAINMENT Li 1. STEEL U 4. FIBERGLASS 10. RIGH)PLASTIC U 90. NONE U 99. OTHER (Specify) 4641 464'1 RISER SECONDARY CONTAINMENT ArLSTEEL 0 4. FIBERGLASS 0 10. RIGH) PLASTIC 0 90. NONE 0 99. OTHER (Specify) 464t 464k1 FILL COMPONENTS INSTALLED 1. SPILL BUCKET JR2. STRIXER PLATFIBOTTOM PROTECTOR 0 4. CONTAINMENT SUMP 451st VI. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS El 90. NONE 469a CONSTRUCTION MATERULL 1. STEEL ❑ 4. FIBERGLASS 10. RIGH) PLASTIC ❑ 99. OTHER (Spacify) 4696c VII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION 448_ IX. APPLICANT SIGNATURE CERTIFICATION: I cerdfy that this UST system is compatible with the hazardous substance stored and that the information provided herein N brae, accurate, and in full counRibince with legal re uirements. APPLI" DATES Oro. 471 APPLICA�'J'�AME� APPLICANT TITLE 4r y,�-,-,` /Vi G /L UPCF UST -B-1/2 Rev. (12/2007)