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n UNIFIED PROGRAM CONSOLIDATED FORM ' UNDERGROUND STORAGE TANK ° OPERATING PERMIT APPLICATION-TANK INFORMATION(One farm per us-]) TYPE OF ACTION (Chmil me item only. For an UST permanent closure or remove],camplx orb^this section xmd Sections 1,11,III,IV,end IX below) 430 ❑ 1.NF,W PERMIT ❑ 3-RENEWAL PLRMtT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE Q 7.UST PFRMAIVF,'NT CLOSURE ON SITE ® S.UST REMOVAL J DATE UST PEMWNENTLY CLOSED: .... I DATE EXISTING UST DISCOVERED: 4;c6 I. FACILITY INFORMATION AAC2ITY ID 4(,!g¢r3cy U.4e Ott(y,) BUSINESS NAME(Sam:ss FACILITY NAME or DBA•Doinrg Bminess AS) W.L.Harris Trust BUSINESS SITE ADDRESS 19: I CITY Ia 16051 E.Mello Ave n---- II.TANK DESCRIPTION . TANK ID# NA 4J= 'TANK MAN(JiFACTUP.ER a» TANK COWIOURATION:T111$TANK IS 434 II]1kRaWn M I.A Sl ATU-ALQ'S TANK ❑2.ONE IN A COMPARTMENTED UNIT. DATE L'STSYSTEA1WST.ALLED 43s r°"'I"`°°° `°�'°°°^�^ in the w4. TANK.CAPACITY IN GALLONS sss NIAiDER Or COMPARTMENTS IN THE UNIT 4s: -1977 5 0 ) TIL TANK USE AND CONTER`TS i TANKUSE U Ia MOTOR VEHICLE FUELING ❑ 1h.MAMNAFUELING ❑ Ic.AVLATIOT'FOf WG 439 13S,CH�IICALPRoDOCT$TORAGE ❑ 4.HAZARDOUS WASTE pn<lWm Used 08) 0 5.EI,iIMGENCY GERERATOR FUEL(MC 925n)itc)l ❑ 6.OTHER Gc IERATOR FUEL ❑ 95.uNr-No N © 99.OTHER(Sree,N): FaM1 Tank 43% CONTENTS PETROLEUbr ® la.REGULAR UNLEADED ❑ Io.MIDGRADE IIM.EADED ❑ ib.PRE4llUM UNLEADED 440 X 3.DIESEL ❑ 5.IET FUEL ❑ b.AVIATION GAS ❑ S.PEFROLEUM BLEND FUEL 0 %GDIERPETROLEUI,f (Speci '): Mon NON-PErROLEUNI:.El 3.USED OIL ❑ 10 L•litmNOL El I1.OTfIER NON-REIROLEUNI(Smit). ,NN, IV. TANK CONSTRUCTION TYPE OF 7Ahw ® l.SLNGCE WALL ❑ 2.DOI78LE WALL. ❑ 95-Utrl.'NOWN st; PRIMARY CONT!+INP.IEN'C r] I SECOh73ARY r] %.STEEL-Ih7R*i.❑A4 T.NIN GRGLASS IJ 6LV'I'E[tNAL yy4 13 95.UKON MOTHER ] 4444CONTPN ❑ LSTEEL FiBERGLISS E-'.TEMORMEMBR9NELWER El ?.JACKETED 445 ® 90.NONE n 99.UNI.NOWti rJ 99.OTHER'SctCi ): use OVERFILL PItEVEND01r ❑ 1.AU0I5LE @V6UAL.AL.VLVi5 ❑ ?.BALL flAAT U 3.FILL TUBE SHUT-0PF VALLA% ns± ❑a,TA\'((LETS REOUIRZ%IEITS FOR EXEMPTION FROM OVERFILL PREY-eSTION EQL7PMFM _ V, PRODUCT/WASTE PIPING CONSTRUCTION 5-TIG C0NSTRUCrfON IT i.SndGLE-WALLED ❑2.D0-uBLE-`A'AIi,ED ❑99.OTHER 4y1 s`,'STEM7VPE ❑ 1.P,2ESSORE ❑ ?:GRAYI"Y 3.C0\iVkYT!0)7lU.SUCTION ❑ ¢:S.AFE SUCITON CCR 4a„6fz ) 45a ' PRRMACYCONTAINMENI EJ 1.STEM ❑S.FIBliMiLASS U S.FLEXIBLE ❑ i9:RSGID PLAS'GC 453 ❑ 90.NONE. ❑ 95.UNKNOWN: ❑ 79.OTHER(SP49ifyk 4oax SECONDARY CON3AINA¢NT [] 1.STLFt ❑ +_FmERGI.ASS ❑ S.FLEXBLE ❑ Ie.RIGID PLASTIC 4646 P3P1NQl1TfRHRaBC n 0 90.NGNE ❑ 95.m4noWN ❑ 99 OTRERtspeeQy): so ) OM.JhMFNT SiIMP TYP6 ❑ 150rGLE WAlL ❑ "DO-731,E WALT 19 90 NONEWy. V7.VENT,VAPOR RECOv"ET2 r(VK)AND RISER/FILL PIPE PIPING CONSTRUCTION ' VENTPR1Fb1RY CONTAAbIfiNT ❑-I.$TF.EL ❑3.FISERGLASS Q IO.MGOJ PIASTIC m 9O.NO?✓F ❑ 99 (TINmt(Specifpj 4etc YENTS UNDAde:Y COMAINdM Ii451et ❑ I.3TEEL ❑9 FIBERGLASS 10.R[GD PLASTIC W 9p.NONE ❑ 49.OT3ER(Spafi^) 4N( VR WENfARY CANTAnQ Ch F 4E4n U 1.STEEL ❑4.F[BERGL AS5 fO,RIGm PLASTfC ® 90.NOHT_ 99-0 ' (specify) 4wS LTRSECONDARM'Y CONI mml ❑ LSTEEL ❑ 3YIBFRGLASS ❑ 10.RMIDPLASTIC ® 90.NOXF ❑ 99.OT!4E8{SPcciry) 4sni t VENT PL✓fNaT YtcgMS[r10N 5U.1".PTYYE 1.SINGLE IVALL ]_ J�n� _1mLEIb WALL 29 go-NONE arai, RiSIItI'RIMARY CAITALNMENT ❑ 1.STEEL ❑4.FIBERGLASS ❑ (O.RIGDPL4.4TTC ® ?O.NONE L1'99.OTHER(Sp¢ifyl 4wj RISERSECONDARYCONTAINMGN7 ❑ 1.STEEL 464j]i ❑ A.EIDFiliGLASs ❑ 10.RICIDPLAS'fIG ® 91).NONE ❑ 99.OTHER(Specify) 464k FIL�.-0k9''ONENiS TNS7ALLE0 ❑ L5Pi1,L BU�:lFf' ❑i.STRfJO:R PLATF.A30TTC]S PROTECTOR ❑q,CONigIx%ImltTSUMP s it VII.1UNDER DISPENSER CONI'ATNMENT(UDC) CONSIRUCI'ION TYPE _ ❑ 1.SINGLE WAU. ❑ 2DOUBI,F.WALL L� 3.NO DISPENSgR$ ® 9a.?iONL• asp.. CONSTRUCTION MATERIAL ❑ 1.STEEL ❑i,FIl3ERGLA55 ❑ IQ.ft[CiD PL,9$'I1C ❑ 99,OTHF,R(S 'fy) 469-9 Tat COMPONENT VIII, CORROSION PROTECTION C1 3 SACRIFICIAL AAODD(S) ❑ 4 INIPM 443. IM APPLICANT SIGNATURE CE3.IFSAT"JOh, I cfrnfy that-t-bis-US--T system is computibte will,the nazarnaus subsmnce scored and that the mformat(au provided herein is true,accurateAPPLII anti in toil com Banc '-b I 1 meats. � CANT SIGNATURE DATE 20 -j 4,c. APPLICANT NA-ME(Print) 1 / APPLICANTTITLE/ an. Alkwer UPCF UST-13->n Rev.(7272{1()7)