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,TFIED PROGRAM CONSOLIDATED. UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per us-I) TYPE OF ACTION (Check one item only. For an UST pernme t closure or removal,complete only this section and Sections 1,11,111,IV,and IX below) 430 ,[3"1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 41 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 BUcSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 BUS ESS SITE ADDRES 103 CITY 104 H.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 3 [11.A STAND-ALONE TANK YE-jeA�� ❑2.ONE IN A COMPARTMENTED UNIT. C=PktC oa P19C for CKII ®the am. DATE UST PYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 go103 'kObO III.TANK USE AND CONTENTS TANK USE R la MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ 1c.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Iwhdm Used OU) ❑ 5.EMERGENCY GENERATOR FUEL[HSC p5281 s(e)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 43% CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED O Ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 !®'3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 11.OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION TYPE OFTANK ❑ 1.SINGLE WALL 0 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE Is 95.UNKNOWN [199.OTHER(s ify): 445a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2_BALL FLOAT FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED Q 2.DOUBLBWAII ED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(a1(3)1 458 PRIMARY CONTAINMENT ❑ 1.STEEL [off 4.FBERGIASS Q 8.FLEXIBLEpec ja O 10.RIGID PLASTIC 464 O 90.NONE 95.UNKNOWN ❑ 99.OTHER(s ify):/f 464a SECONDARY CONTAINMENT ❑ 1.STEEL 10 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING[TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 464e 464ei VENT SECONDARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 464f 464) VR PRIMARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 4646 464g I VR SECONDARY CONTAINMENT I.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 464b 464hl VENT PIPING TRANSITION SUMP TYPE 0 1.SINGLE WALL fit 2.DOUBLE WAIL 0 90.NONE 4ML RISER PRIMARY CONTAINMENT 1.STEEL Lid 4.FIBERGLASS U 10.RIGID PLASTIC Ll 90.NONE Ll 99.OTHER(Specify) 4641 464'I RISER SECONDARY CONTAINMENT 1.STEEL a4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464k 464kl FILL COMPONENTS INSTALLED 1.SPILL BUCKET MZI STRIKER PLATF/BOTIOM PROTECTOR RL4.CONTAINMENTSUMP 45lac VII.UNDER DISPENSER CONTARiMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL O 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC O 99.OTHER(Specify) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system is eoMpatible with the hmrdeas substance stored and that the information provided herein is true,accurate, and In fall compliance with legal reagmWft APPLICANT SIGNATUREf2 DATE 470' � a�i9/l a APPLICANT NAME(print) t fir 971' APPLICANT TITLEO cu N 4r-. n7oAb itMF�J k N9 UPCF UST-B-1/2 Rev.(12/2007)