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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (one form per UsT) TYPE OF ACTION (Check one item only. For an U ermanent closure or removal, complete only thus section and Sections I, II, III, IV, and IX below) 430 SRENEWAL 1. NEW PERMIT PERM PERMIT ❑ 5. CHANGE OF INFORMATION 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 43oa DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) I BUSINESS NAME (Same as FACILW NAME D ess As) 3 ��AD'y9�'pg -Bus G fvlli� to3 BUSINESS 91TE ADD SS` n CITY 104 (( lV ,- - II.. TANK DESCRIPTION TAMC ID # 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 [11. A STAND-ALONE TANK EVONE IN A COMPARTMENTED UNIT. Com Icle one pagefor each compartnent in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPj,� IN GALLONS 436 NUMBER OF CO ARTMENTS IN THE UNIT 437 III. tANK USE AND CONTENTS TANK USE R ]a. MOTOR VEHICLE FUELING ❑ ]b. MARINA FUELING ❑ lc. AVIATION FUELING 439 (] 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Includes Used Oil) [15. EMERGENCY GENERATOR FUEL [HSC §25281 5(c)] ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la REGULAR UNLEADED ❑ lc. MIDGRADE UNLEADED ❑ lb. PREMIUM UNLEADED 440 W3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9.OTHERPETROLEUM (Specify): 44N NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ❑ 11.OTHER NON -PETROLEUMS 440n IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ML 2. DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1. STEEL Ejr3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 ❑ 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1. STEEL QD. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 445a OVERFILL PREVENTION ❑ 1. AUDIBLE & VISUAL ALARMS ❑ 2. BALL FLOAT qL 3. FILL TUBE SHUT-OFF VALVE 452. ❑ 4. TANK MEETS REQUIREMENTS FOREXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT / WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1. SINGLE -WALLED 10L DOUBLE -WALLED ❑ 99. OTHER 460 SYSTEM TYPEPRESSURE [12. GRAVITY El3. CONVENTIONAL SUCTION ❑ 4. SAFE SUC170N 123 CCR y2636(a)(3)) ass PRIMARY CONTAINMENT 1. STEEL 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGIDPLASTIC 464 ❑ 90. NONE 95. UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1. STEEL _W4. FIBERGLASS ❑ S. FLEXIBLE ❑ 10. RIGID PLASTIC 4 [36ab 90. NONE Lj 95. UNKNOWN ❑ 99. OTHER (Specify): 464c PIPINGITURBINE CONTAINMENT SUMP TYPE ❑ 1. SINGLE WALL DOUBLE WALL ❑ 90. NONE 4644 VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1. STEEL 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464c 464el VENC SECONDARY CONTAINMENT ❑ 1. STEEL QL4_ FIBERGLASS ❑ 10. RIGIDPLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464r 464fl VR PRIMARY CONTAINMENT ❑ 1. STEEL PL4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464g 4641 VR SECONDARY CONTAINMENT ❑ 1. STEEL WA FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE L SINGLE WALL EW. DOUBLE WALL ❑ 90. NONE 4641. RISER PRIMARYCONTAINMENT $.1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Spcc]fy) 464j 464'1 RISER SECONDARY CONTAINMENT ❑ 1. STEEL 4_ FIBERGLASS 10. RIGID PLASTIC ❑ 90. NONE ❑ 99.OTHER (Specify) 464k 464k1 FILL COMPONENTS INSTALLED JLL SPILL BUCKET Er 3. STRIKER PLATFJBOTTOM PROTECTOR NE4. CONTAINMENT SUMP 45la-c VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ❑ 1. SINGLE WALL M2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 469a CONSTRUCTION MATERIAL ❑ 1. STEEL 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 4696, VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION 440. 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 com 1 nce with legal requirements. APPLICANT SIGNATURE DATE 470• APPLICANT NAME rin 471. APPLICANT TITLE 47' t UPCF UST -B -1/2 Rev. (12/2007)