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oc <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One form Per UST) <br /> TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11,111,ry and IX below) 43 <br /> ❑ L NEW PERMIT ❑ 3.RENEWAL PERMIT N 5.CIIANGH OF INFORMA'T'ION <br /> ❑ 6.TFIMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE:ON SITE 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 4301 DATE EXISTING UST DISCOVERED: awe. <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) -BUS ES S NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> ARP Mi imXLT C UNION 76) <br /> BUSINESS SITE ADDRIiSS 103. 1 CITY 104_ <br /> ZS -7-75 S . Pfr-r 1_16 as O IJ poll kD TPRc <br /> II. TANK DESCRIPTION <br /> TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434. <br /> ch <br /> 31 R/ 70%D X C R X F_ S ❑ z:or STAND-ALONE A COMPARTMENTED UNIT C W�n t. <br /> DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 426. NUMBER OF COMPARTMENTS IN THE UNIT 437. <br /> 1qq3 to Ooo IONE <br /> III. TANK USE AND CONTENTS <br /> TANK USE ® la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc.AVIATION FUELING 439. <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(IwJudo Uscd Oiq ❑ $.EMERGENCY GENERATOR FUEL(HSC t25251.5(c)] <br /> ❑ 6,OTHER GENERATOR FUEL __ ❑ 95.UNKNOWN ❑ 99.O1n1*R(Specify): 4394 <br /> CONTF,NTS PETROLEUM: ® la.REGULAR UNLEADED ❑ I c.MIDGRADE UNLEADED `❑ Ib.PREMIUM UNLEADED 440. <br /> ❑ 3.DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 4404 _ <br /> - NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ 11.OTHEtNON-PETROLFUM(Specify): 440b. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL W 2.DOUBLE WALL ❑ 95.UNKNOWN _ - _ 443. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL og 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): _.444. <br /> SECONDARY CONTAINMENT ❑ I_STEEL 9 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED X445. <br /> _ <br /> 0_90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445x. <br /> OVERFILL PREVENTION CZ 1.AUDIBLE&VISUAL ALARMS ® 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452 <br /> 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL.PREVENTION EQUIPMLNT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑ 1.SINGLE WALL 0 2.DOUBLE WALL ❑ 99.OTHER 460 <br /> SYSTEM TYPE 0 1.PRESSURE ❑ 2.GRAVITY 0 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR_12636(ax3) 454 <br /> PRIMARY CONTAINMENT ❑ 1.STEEI, El 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ I0.RIGID PLASTIC 464 <br /> _ ❑ 90.NONE_ _❑ 95.UNKNOWN ❑ 99-OTHER(Specify): *4a. <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ($ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464e <br /> ❑-90.NONE ❑ 95.UNKNOWN _❑ 99.OTHER(Specify): 4"c. <br /> PIPINGITURBINE CONTAINMENT SUMP TYPE CZ I.SINGLE WALL ❑ 2.DOUBLE WALL. ❑ 9o.NONE 4644 <br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL Cg 4.FIBERGLASS ❑ 10.RIGID PLASTIC [3 90.NONE ❑ 99.OTHER(Specify): 464e1 <br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL C] 4.FIBERGLASS ❑ 10.RIGID PLASTIC N 90.NONE [3 99. (Specify): 464£ <br /> _ _ a64n. <br /> VR PRIMARY CONTAINMENT ❑ I.STEFI. (g 4.FIBERGLASS ^❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4646 <br /> VR SECONDARY CONTAINMENT ❑ I.STEEL E] 4.FIBERGLASS ❑ 10.RIGID PLASTIC 19 90.NONE 1199.OTTFR(Specify): 464hl . <br /> VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE.WALL [32.DOUBLE WALL N 90,NONE 464t <br /> 464j <br /> RISER PRIMARY CONTAINMENT Ia 1.STEEL ❑ 4.FIBERGLASS T❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464i <br /> RISER SECONDARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ lo.RIGTD PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4641' <br /> _ 4601. <br /> FILL COMPONENTS INSTALLED 1.SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR in 4.CONTAINMENT SUMP asta-� <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ® 1.SINGLE WALL [32.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE a <br /> CONSTRUCTION MATERIAL [31.STEEL ® 4.FIBERGLASS [310.RIGID PLASTIC ❑ 99.OTHER(Specify) - 469. <br /> 469c <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 4". <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION:I certify that this UST system Is compatible with the hazardous substance stored and that the information provided hereiZ is true, <br /> accurate,sad in full compliance with leigal requirements. <br /> APPLICANT SIGNATURE 4:1;m <br /> ;m !Q DATE. L 2,0 D 470. <br /> APPLICANT NAME(print) G,Q ATEL 471. APPLICANT TITLi T R G A S RE 72 <br /> UPCF UST-B Rev.(1212007)-1/2 www.unidocs.org <br />