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0k4P "rla UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form UST) TYPE OF ACTION (Check one item only. Foran UST permanent closure or removal,complete only this section end SegI..I,II,III,IV,and IX below) 4.70 ❑ L NEW PERMIT ❑ 3,RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE S.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4JW DATE EXISTING UST DISCOVERED 430b L FACILITY INFORMATION FACIL 11 Y ID q(Agency Use Only) _ _ grl 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 Super Store Industries BUSINIiSS SITE ADDRESS 103CIathIM loo i AAA McKinley Ave If.TANK DESCRIPTION TANK ID a 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 X M - LA STAND-ALONE TANK J U,/ 8 2.ONE M A COMPARTMENTED UNIT. Can mom torah uaiq wik ATE UST SYST M fNSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 111.TANK USE AND CONTENTS TANK USE ❑ Ia.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUEL 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(l Il 11 NOit) S.EMERGEN ERATOR FUELI 6'- SMI ❑ 6.OTHER GENERATOR FU EL ❑ 95.UNKNOWN 99.OTHE (S i ):Fresh Oil +39a CONI'EN"fS PETROLEUM: ❑ 1..REGULAR UNLEADED ❑ le.MIDGRADEUNLEADED ❑ Ib.PREM W ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL 0 9.OTHER PETROLEUM S i : 440s NON-PETROLEUM:U 7.USED OIL ❑ METHANOL 11.OTHER NON-PETROLEUMS i : 4gab IV. TANK CONSTRUCTION n PE OF-TANK ❑ L SINGLE WALL 2.DOUBLE WALL 95.UNKNOWN 443 PRI.MAR t'CONTAINMENT 1.STEEL JU 3.FIBERGLASS ❑ 6.INTERNAL BLADDER IIq ❑ 7.STEEL.INTERNAL LINING 011. UNKNOWN ❑ 99.OTHER (Specify): 414 SECONDARY CONTAINMENT ❑ 1.STEEL KI 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7,JACKETED M5 ❑ 90.NONE ❑ 95.UNKNOWN 99.OTHER S 05. OVERFILL.PREVENTION I.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHIFT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION "PIPING ❑I.SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER 460 St'STE)I ll'PE ❑ LPRESSURE 2.GRAVfN ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION F23 CCR#2636(a)(3)] 458 I PRIMARY CONTAINMENT ❑ I.STEEL 3P 4.FIBERGLASS ❑ &FLEXIBLE PLASTIC O 90.NONE .[I ❑ 10.RIGID q61 95.UNKNOWN ❑ 99.OTHER'S peeify): 464a j SECONDARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS ❑ B.FLEXIBLE ❑ 10.RIGID PLASTIC I641, ❑ 90.NONE 95.UNKNOWN 0 99.OTHER(S city): W6 ' PIPINGr:U:RBINE CONTAINMENT SUMP TYPE ❑ I.SINGLE WALL 02.DOUBLE WALL [71 90.NONE 46M VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION ENT PRIM ARY CONTAINMENT I.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 99.OTHER IS, qWe VENT SECONDARY CONTAINMENT 1.STEEL q.FIBERGLASS 10.RIGIDPLASTIC 90.NONE 99.OTHER(Specify) IUf VR PRIMARY CONTAINMENT I.STEEL 46111 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4us VR SECONDARY CONTAINMENT 1.STEEL W q.FIBERGLASS 10.RIGID PLASTIC 164 1 90.NONE OTHER(Specib) 464h EN7?IPI\G TRANSRION SUMP TYPE 464b1 I.SINGLE WALL 2.DOUBLE WALL 90.NONE g64i. RISER PRISIARY CONfAMMEN'f 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) gbtj q6'1 RISER SEClNDARY CONTAINMENT LSTEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) q k FILL COMPONENTS INSTALLED 1.SPILL BUCKET W3.STRIKER PLATFIBOTTOM P 46 k1 ROTECTOR 4.CONTAINMENTSUMP 431. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRCC NON TYPE LSINGLE WALL ❑ 2.DOUBLE WALL ❑ 1N0 DISPENSERS ❑ O.NONE 469a CONSTR!'CfION MATERIAL ❑ 1.STEEL 4.FIBERGLASS 10.RIGID PLASTICi 99&OTHER(Specify) 469b c i VIII. CORROSION PROTECTION STEEL C( %1PONE.NT PROTECTION ❑ 2.SACRIFICIAL ANOORS) ❑ 4.IMPRESSED CURRENT ]II 6.ISOLATION +48. IX. APPLICANT SIGNATURE CERTIF I C:kTION: 1 cenify,that this UST system Is compatible with the hazardous substance«orad and that the Iuformatioo provided herein b true,accuratq and In fug com Bance with legal requirements. aPPLIC:+.N-! 1 ATURE DATE Oro. Z- _ o APPLICANI'NAME(print) L qn. APPLIC�N�'TITLE 4n.. Kevin Selby Facility Manager/Operations Mgr. L PCF US I%11-1/2 Rev.(12/2007)