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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,IV,and IX below) 430. <br /> ❑ I.NF.W PERMIT ❑ 3.RENEWAL PERMIT 1?5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE El 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 43oh. <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3- <br /> ARP Mi imXLT c UNION 76) <br /> BUSINESS SITE ADDRESS 103 CITY 104. <br /> 2 5 -7-7 5 S PH-��- �a� PFlss TRRc <br /> H. TANK DESCRIPTION <br /> TANK ID# 432 TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434, <br /> 1 x v r p v ❑ 1.A STAND-ALONE TANK Compkte one Page for each <br /> 1� /� S ❑ 2.ONE IN A COMPARTMENTED UNIT comm mrnt in the une. <br /> DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. <br /> 1qq3 10 1000 ONS <br /> M. TANK USE AND CONTENTS <br /> TANK USE ® la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Ic.AVIATION FUELING 439. <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(mhWn Used 00) ❑ 5.EMERGENCY GENERATOR FUEL.[HSC 125281.5(c)) <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a <br /> CONTENTS PETROLEUM: ❑'Ia.REGULAR UNLEADED _.._.._El la MIDGRADE UNLEADED C3 1b.PREMIUM UNLEADED 440. <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> _❑ 8.PETROLEUM BLIND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440a <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUMS 440b. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL _2.DOUBLE WALL ❑ 95.UNKNOWN443. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL 3.FTBERGIASS ❑ 6.INTERNAL.BLADDER _ 444. <br /> ❑ 7.STEEL+INTERNAL LINING 0 95.UNKNOWN El 99.OTHIIt(Spxify): tea. <br /> SECONDARY CONTAINMENT ❑ 1.STEEL JZ 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Simify): 445a <br /> OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 0 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. <br /> ❑ 4.TANK MEFrS UIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑ 1.SINGLE WALL 0 2.DOUBLE WALL ❑ 99.OTHER _4 <br /> SYSTEM TYPE 9 1.PRESSURE ❑ 2.GRAVITY 0 3.CONVENTIONAL SUCTION ❑-4_SAFE SUCTION(23 CCR 12636(ax3)1 458 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL Il 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 <br /> __ [190.NONE C1 95.UNKNOWN ❑_99.OTHER(Specify): 464x. <br /> SECONDARY CONTAINMENT ❑ i.STEEL I$4.FIBERGLASS ❑ 8.FLFAIBLE ❑ 10.RIGID PLASTIC 464b <br /> ❑ 90.NONE_ ❑ 95.UNKNOWN _❑ 99.OTIIER(Specify): 4640. <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE CR 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 <br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL 19 4.FIBERGLASS ❑ l0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464e <br /> _ 464e1. <br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ lo.RIGID PLASTIC 9 90.NONE ❑ 99.OTHER(Specify): 464.. <br /> _ 464n. <br /> VR PRIMARY CONTAINMENT L. I$❑ 1.STEEL 4.FIBERGLASS 13t0.RIGID PLASTIC [390.NONE ❑ 99.OTMR(Specify): 4664as <br /> VR SECONDARY CONTAINMENT [j L STEEL [34.FIBERGLASS C1 10.RIGID PLASTIC 0190.NONE 1199.OTHER(Specify): 4664h1. <br /> -- ---.__- _.-.......... <br /> VENT PIPING TRANSITION SUMP TYPE _ [31.SINGLE WALL ❑ 2.DOUBLE WALL Iff 90.NONE 464` <br /> 4 <br /> RISER PRIMARY CONTAINMENT 2g1.STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC E390.NONE [399.OTHER(Specify): ah4fla 1. <br /> 464- <br /> RISER SECONDARY CONTAINMENT [11.STEEL. jj 4.FIBERGLASS ❑ 10.RIGID PLASTIC [3464k 90.NONE ❑ 99.OTHER(Specify): 6 . <br /> 41 I. <br /> FILL COMPONENTS INSTALLED BT 1.SPILL BUCKET 19 3.MRIKER PLATEIBOTTOM PROTECTOR 214.CONTAINMENT SUMP 451a-c. <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CON_ST_RUCTION TYPE j$ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469& <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL. IN 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) °469c <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. <br /> M APPLICANT SIGNATURE <br /> CERTIFICATION:1 certify that this UST system is compatible with the hazardous substance stored and that the information provi herein is true, <br /> accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE rG Q TETT DATE 470 <br /> L ZOO 4 <br /> APPLICANT NAME(print) Cry QA Tc L a1. APPLICANT TITLE T RG A 5 RE 472 <br /> I IPCF UST-8 Rev.(12/2007)-1/2 www.unidoes.org <br />