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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK t <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) <br /> TYPE OF ACTION (Check ore irem only. For a UST closure or removal,complete only this section and Sections 1,11,111,11;and JX below) 430. <br /> ❑ I.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ S.CHANGE OP INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 0 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 4300. DATE EXISTING UST DISCOVERED: 4306. <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) _ _ <br /> BUSINESS NAME(Se4 eas • chi)Nam¢or DBA-DoingDusiness As) 3. <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> ¢219 ov0.4� �- L0.he. S'jt)C.147 <br /> II. TANK DESCRIPTION <br /> TANK ID# $-15.7931 TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. <br /> 0 d V ✓QS ElI.A STAND-ALONE TANK Camplm one P.,fur.1, <br /> /bG 2.ONE INA COMPARTMENTED UNIT mmpunmem in 0,c unit <br /> DATE UST SYST M INSTALLED 435. TANK CAPACITY IN GALLONS 436, 1 NUMBER OF COMPARTMENTS IN THE UNIT 437. <br /> 012-1 12.101 <br /> III. TANK USE AND CONTENTS <br /> TANKUSEIaM CRVEHICLE FUELING ❑ Ib.MARINA FUELING ElIC.AVIATIONFUELING 439. <br /> ❑ 3,CHEMICAL PRODUCTSTORAGE ❑ 4.HAZARDOUS WASTE Onaud Uwd Oil) ❑ 5.EMERGENCY GENERATOR FUEL[Hsc jm263,5(c)I <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN 0 99.OTHER(Specify): 4394. <br /> CONTENTS PETROLEUM: ❑ In.REGULAR UNLEADED ❑ Ie.MIDGRADEUNLEADED Ib.PREMIUM UNLEADED 440. <br /> ❑ 3.DIESEL ❑ 5.JET FUEL 0 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHERPETROLEUM(Specify): 4404_ <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ <br /> 11.OTHER NON-PETROLEUM(S «i ): 44M <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK El I.SINGLE WALL X2.DOUBLEWALL 95.UNKNOWN 443. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL �X3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(S if): 4440. <br /> SECONDARY CONTAINMENT 0 1.STEEL JK3.FIBERGLASS 0 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. <br /> El 90.NONE 095.UNKNOWN ❑99.OTHER(specify): 445. <br /> OVERFILL PREVENTION ] 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT [13.FILL TUBE SHUT-OFF VALVE 451 <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑ 1.SINGLE_WALL 2,DOUBLE WALL 0 99.OTHER 460. <br /> SYSTEM TYPE X I.PRESSURE ❑ 2.GRAVITY ❑ 3.CDNVENTIONAL SUCTION E1j.SAFE SUCTION I33 CCR§3636(0)(3)1 458, <br /> PRIMARY CONTAINMENT ❑ L STEEL U4.TIBERGLASS ❑ 8.FLLXIBLE EI 10.RIGID PLASTIC 464 <br /> ❑ 90.NONE_ ❑ 95.UNKNOWN ❑ 99.OTHER(SP cify): 4644. <br /> SECONDARY CONTAINMENT 0 1.STEEL aid 4.FIBERGLASS ❑ a.FLEXIBLE ❑ 10.RIGID PLASTIC 45h <br /> ❑ 90.NONE ❑ 95.UNKNOWN 0 99.OTHER(Specify); 4644 <br /> PIPINGA-URBINE CONTAINMENT SUMP TYPE 0 L SINGLE WALL A 2.DOUBLE WALL ❑ 90.NONE 464d. <br /> VI. VENT,VAPOR RECOVERY(VR) AND AISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT 01.STEEL 4.FIBERGLASS 010.RIGIDPLASTIC [1 90.NONE ❑ 99.OTHER(Spccify)1 T64-.: <br /> VL'-NT SECONDARY CONTAINMENT ❑ !.SffiEL .g 9.PIBEROLASS 0 10.RIGID PLASTIC [190.NONE ❑ 99.OTHER(Specify): 4M�' <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL lff4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE El99.OTHER(specify): 446 <br /> 49s <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL X4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHERS a 46411. <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL X'2.DOUBLE WALL ❑ 90.NONE 91 <br /> RISER PRIMARY CONTAINMENT STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify): 4641 <br /> �� -_ _ I fY} 469'1. <br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIDERGLASS _0 10.RIG ID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify); <464k <br /> FILL COMPONENTS INSTALLED .SPILL BUCKET RL 3.STRIKER PLAT PROTECTOR u 4.CONTAINMENT SUMP 510'0. <br /> VII. UNDER DI ENSER CONTAINMENT (UDC-) <br /> CONSTRUCTION TYPE ❑ ].SINGLE WALL X 2.DOUBLE WALL 3.NO DISPENSERS 0 90.NONE P. 46% <br /> CONSTRUCTION MATERIAL ❑ I.STEEL 4.FTBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4694. <br /> VIII. CORROSION PROTECTION C;�`i <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) 04AMPRESSED CURRENT 6.ISOLATION <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that ibis UST system is compatible with the hazardous substance stored and that the information provided he rne, <br /> accurate,and in full eo 3 fiance with legal requirements. �.. <br /> APPLICANT SIGNATURE DATE 7, 'S, 09 470' <br /> APPLICANT NAME(prim) (lPu� i A Jy�-p 971 APPLICANT TITLE 6%r.. Q» Ja at <br /> f L 47 <br /> UPCF UST-B Rev.(122007)-112 `t uivw.unidocs.o5g <br />