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. -7 )6/oti 0 eV <br /> UNIFIED PROGRAM CONSOLIDATED FORM {� / l�/p q <br /> UNDERGROUND STORAGE TANK k l C <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) <br /> TYPE OF ACTION (Check one item only. Fara UST closure or removal.complete only this sectimi mid Seclions 1,11,111,11;and IX belou) 430, <br /> ❑ L NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> 6.TEMPORARY USTCLOSURE 0 7,USTPERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430- 1 DATE EXISTING USTDISCOVERF.D: 4301,. <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Opd;) _ _ ' 1_ <br /> BUSINESS NAME(Sone as Facp'q'None or DRoing Business As) 3. <br /> 'S L -D # 5(4 <br /> HUSINES SITEADDRESS 103. CITY 104. <br /> 44-21 Moro-J.a- L"r, TDCKToN <br /> H. TANK DESCRIPTION <br /> TANK ID rC> .57/5--7432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. <br /> 87 ❑ 1.ASTAND-ALONE TANK Complete ane p.ae fore h <br /> D� r e 2.ONE INA COMPARTMENTED UNIT mmpvrcmmr in d,e wit. <br /> DATE UST SY T c INSTALLED 43% TANK C PA ITY IOOOGALLONS 436, NUMBER OP COMPARTMENTS IN THE UNIT 437. <br /> Zak?0 <br /> III. TANK USE AND CONTENTS <br /> TANK USE In.MOTOR VEHICLE FUELING ❑ lb.MARINAPUELING ❑ 1c.AVIATIONFUELING 439. <br /> 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE pnd.&s 2hnd OTO ❑ 5.EMERGENCY GENERATOR FUEL[NSC§25291.5(.)l <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439., <br /> CONTENTS PETROLEUM: Is REGULAR UNLEADED 12 Ie.M1DGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440, <br /> ❑ 3.DIESEL ❑ S-IFT FUEL ❑ 6.AVIATION GAS <br /> ❑ S.PETROLEUM BLEND FULL ❑ 9.OTHER PETROLEUM(Specify): 440s <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ METHANOL <br /> ❑ 11.OTHER NON-PETROLEUM(S wi : 4406. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ LSINGLEWALL2.DOU➢LEWALL ❑ 95.UNKNOWN _ 443. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. <br /> ❑ 7.STEEL+INTERt1XAL LINING ❑ 95.UNKNOWN ❑ 99.OrMRE SpeeiN): 4". <br /> SECONDARY CONTAINMENT ❑ 1.STEEL 2E3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANELINER ❑ 7.JACKETED 445, <br /> ❑ 9D.NONE ❑ 95.UNKNOWN ❑99.OTHER(SPccify): 445. <br /> OVERFILL PREVENTION I.AUDIBLE E VISUAL ALARMS 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 459. <br /> 4.TANK MEETS REQUIRE <br /> R EXEMPTION FROM OV3RFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑ L S1NGL_£_grALL 2.DOU➢LE WALL ❑ 99.OT14FR 4W <br /> SYSTEM TYPE X 1.PRESSURE ❑ ^_.GRAVITY ❑_ 3.CONVENT10NAL SUCTION M 4.SAFE SUCTION 123 CCR J2636(,)(3)] 459. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL $4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464. <br /> 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Spscify); 464. <br /> SECONDARY CONTAINMENT ❑ 1.STEEL X 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify); 464e <br /> PIPINGITURBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 4644. <br /> VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL 3K,4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90,NONE ❑ 99.OTHER(Specify): 4 <br /> _ 4640. <br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ ID.RIGID PLASTIC_ ❑ 90.NONE ❑ 99.OTHER(Spc ify): at. <br /> wn, <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL X 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464,4 ' <br /> VR SECONDARY CONTAINMENT El 1.STEEL )K4.FIBERGLASS [110.RIGID PLASTIC El 90.NONE ❑ 99.OTHER(Spwify): a41 <br /> VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL ),2.DOUBLE WALL ❑ 90.NONE 4MI' <br /> RISER PRIMARY CONTAINMENT I.STEEL X4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify):" "XII <br /> RISER SECONDARY CONTAINMENT ❑ LSTEM. VI 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify):t: q6W[ <br /> FILL COMPONENTS IN STALLED Wi.SPILL BUCKET V3.STRiKERPLATEBOTTOM PROTECTOR 4.CONITAINMENTSUMP 4510-c. <br /> VII. UNDER DISP NSER CONTAINMENT (UDC) <br /> CONSTRUCTION TYPE _ ❑ L SINGLE WALL _2.DOUBLE WALL ❑ 3.NO DISPENSERS �] 90.NONE___ 460. <br /> CONSTRUCTION MATERIAL ❑ I.STEEL x4.FJBERGLASS ❑ 10.RIGID PLASTIC ❑ 99,OTHER(Specify) 46%. <br /> 469.. <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provi rein is true, <br /> accurate in full coo 'ance with lcsmrequirements. <br /> APPLICANT SIGNATURE q e,Q DATE 77 _ V5`09 <br /> 470. <br /> APPLICANT NAME(print) p,w%, �0.v�C#o 97' APPLICANT TITLE•., „9AQ� - E V 4S <br /> UPCFUST-BRev.(12I2007)-U2 www.unidocs.org Y`�` 4 <br />