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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (On-form Per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal.complete only this section and Sections 1.11.111,!Y,and 1X below) 430 ❑ I.NEW PERMIT (:1 3.RENEWAL PERMIT 119 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 43Ca I DA'I E EXISTING UST DISCOVERED awe I. FACILITY INFORMATION FACILITY II)#(Agency Use Only) 4�2 903 1e - - 1. BUS iNESS NAME(Same as Facility Name or DBA-Doing Business As) 3 ARP MINIMP(-T C QN10N 76) BUSINFSS SITF.ADDRESS 103, CITY 104 .- 2,S -7-75 S . P&7 TaS o rJ POss TRAM II. TANK DESCRIPTION TANK 1D# " f T�0 r �B a3z. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 43+ 7 v r ❑ 1.A STAND-ALONE TANK Complete one page for tach ( ^ F R /� e S ❑ 2.ONE IN A COMPARTMENTED UNIT comPaarncni to the unit DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 M3 10 000 2 ONS' III. TANK USE AND CONTENTS TANK USE ® IL MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ 1C.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL(HSC 125291.5(,,); ❑ 6.OTHER GENERATOR FUEL _❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: ® 1a REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 44i1 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS - __ [3 8.PETROLEUM BLEND FUEL. ❑ 9.OTHER PETROLEUM(Specify): 44 Oa _II NON-PETROLEUM:❑ 7.USED OIL ❑ lo.ETHANOL ❑ 11.OTHER NON-PETROLEUM(specify); 44ob. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2 DOUBLE WALT. ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT ❑ 1.STEEL I9 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNY-40WN ❑ 99.OTT IER(Specify): 444x. SECONDARY CONTAINMENT EI 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED -445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445#. OVERFILL PREVENTION e$ 1.AUDIBLE&VISUAL ALARMS ® 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452 ❑ 4.TANK MEETSUIRI•NENTS FOR EXEMPTION FROM OVERFILL PREVENTION E UIPMFNT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ I.SINGLE WALL_ 0 2.DOUBLE WALL ❑ 99.OTHER 460. SYSTEM TYPE 8 1.PRESSURE. __❑ 2.GRAVITY ❑^3.CONVENTIONAL SUCTION [34.SAFE SUCTION 123 CCA 42656(#3 459 PRIMARY CONTAINMENT 131.STEEL ISI 4.FIBERGLASS ❑ 8.FLEXIBLE _ ❑ 10.RIGID PLASTIC 464• ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 461a• SECONDARY CONTAINMENT ❑ 1.STEEL J$4.FIBFRGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4646, ❑ 90.NONE ❑ 95.UNKNOWN 0 99.OTHER(Specify): i"C _ PIPINCvTURBINE CONTAINMENT SUMP TYPE CR 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 9o.NONE 464e VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I.STEEL (g 4.FIIIcRGLASS ❑ 10.RIGID PLASTIC (390.NONE [399.OTHER(Specify): 40 _ 4664e 1 1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 9o.NONE ❑ 99.OTHER(spew: 46at 464n. VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 40154. VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS [310.RIGID PLASTIC 90.NONE [199.OTHER(Specify): 4664hi VENT PIPING TRANSITION SUMP TYPE (31.SINGLE WALL [32.DOUBLE WALL l$90.NONE 4b0` RISER PRIMARY CONTAINMENT ja 1.STEEL ❑ 4.FIBERGLASS [310.RIGID PLASTIC [390.NONE ❑ 99.OTHER(Specify): 464j 46#'1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464k _ 464111. FILL COMPONENTS INSTALLED If 1.SPITZ BUCKET N 3.STRIKER PLATEBOTTOM PROTECTOR 4.CONTAINMENT SUMP 451a-c. VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE. _ ®_1.SINGLE WALL ❑ 2.DOUBLE WALL [33.NO DISPENSERS [390.NONE--=. 469# CONSTRUCTION MATERIAL ❑ 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469,, VIII. CORROSION PROTECTION ' STEEL.COMPONENT PROTECTION ❑ 2.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 hn is true, accurate,and in full compliance with legal requirements. APPLICANT SIGNATURE iDATE 470. ;ra CL 471 lL2O 472 APPLICANT NAME(print) GIRTLTL A TCL E TRGFlSURE�Z IIPCF UST-B Rev.(12/2007)-1R www.unidocs.org