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4 - e T -7 - mmm� W� // 7tio UNIFIED PROGRAM CONSOLIDATED FORM ink ��_ UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. For USTpermanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 430 ❑ 1.NEW PERMIT 3.RENEWAL PERMIT E:15.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE El8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 436a DATE EXISTING UST DISCOVERED: 430b FACILITY ID#(Agency Use Only) L FACILITY INFORMATION ;'7 t B INESS NaADDRES e as FACILITY NAME or DBA-Doing Business As) 3 G B S SI103 CITY104 z H.TANK DESCRIPTIO TANpK ID# �' ` 3 7L✓U 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 132.0 1-33 Z06 R1.A STAND-ALONE TANK R12.ONE IN A COMPARTMENTED UNIT. DATE UST SYSTEM IN TALLED 43s Co rete one for each cora t in the emit TANK C,0.�ACI IN GALLONS a36 NUMBER OF COMPARTMENTS IN THE UNIT 437 �CIn, ONE- l. NEIfI I.TANK USE AND CONTENTS TANK USE 1a.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC 4252g1.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: I&REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM g 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM S eci : 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER S 444a SECONDARY CONTAINMENT 1.STEEL [13.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 Fl 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S ify): 445a OVERFILL PREVENTION I.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 4s2. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGL&WALLED Q%2.DOUBLE-WALLED El 99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCA§2636(e)(3)] 438 PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT AI.STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4641, ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/IURBINE CONTAINMENT SUMP TYPE 9 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT P,1.STEEL }_ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e VENT SECONDARY CONTAINMEM ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE El 99.OTHER(Specify) 464f VR PRIMARY CONTAINMENT LJ 1.STEEL 4.FIBERGLA4601 SS ❑ 10.RIGID PLASTIC El90.NONE 0 99.57THER(Specify) 464g VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS4641 ❑ 10.RIGID PLASTIC ❑ 90.NO 99.OTFIER(Specify) 4641, VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 464h I 2.DOUBLE WALL ❑ 90.NONE 4641 RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC El 90.NONE ❑ W.OTHER(Specify) 464j RISER SECONDARY CONTAINMENT El1.STEEL 4.FIBERGLASS LJ10.RIGID PLASTIC E] 90.NONE ❑ 99.OTHER(Specify) 4464k FILL COMPONENTS INSTALLED I.SPILL BUCKET IMM 3. ki KER M OR ❑ 4.CONTAINMENT SUMP 451., VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE S11.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL. 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION .SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full corn liance with legal requirements. ICANT SIGNA DATE / 470. 'LC AP CA N rint 471. ICA TITLE 472. �, UPCF UST-B-1/2 Rev.(12/2007)