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UNIFIED PROGRAM CONSOLIDATED FORM UiNOERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One forin per )ST) 450 TYPE OF ACTION (Check one item-only. For an UST pe_manent closure of removal.complete Onh this Sec[iotl and Sectigrs L 117[!I.IV.and) below) ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGg OF INFORMATION ❑ b.TEMPORARY UST CL OSURE 7.UST PER�?A\ENI CLOSURE ON SITE S.UST REMOVAL 4306 DATE UST PERMANENTLY CLOSED: aiO9 DATE EXISTING UST DISCOVERF,D: T. FACILITY INFORMATION I FACILITY ID'4(Agana'Use Only9 BUSINESS NAME(Same as FACILI I Y NAME_or unA-Doing Ousiness As) BUSINESS SITE ADDRESS iO3 CITY SP1 II.TANK DESCRIPTION TANK IDu 43' TANK MANUFACTURER 43, TANKCONFIGLRATION: TFIISTANK IS 431 61.A STAND•ALON'13 TAT 2.ONE IN A COMPARTME\7ED UNIT. compieteempasgfor etch companinent is tha unit DATE UST SYSTEM INSTALLED °35 TANKS Pr1.ITY 1 'GALLONS X36 NUMBER OF COMPARTMENTS IN THE-Utl 43-' II.TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUEL)NG ❑ Ic.AVIATION FUELING 430 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.14AZARDOU5 WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL(HSC§2!261sic}I GJ 6.OTHER GENERATOR FUEL ❑ 95.0KNOAN ❑ 99,OTH& (Specify): 430a CONTENTS PETROLEUM: IQ )e.REGULAR UNLEADED �I Ic,SIIDGRADE UNLEADED W Ib.PRF_\41L'\d UNLE.AUED 440 El 3.DIESEL a 5.JET FUEL ❑ 6.A\rjA tON GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEL'>t (S cifv): 44% NON-PETROLEL:'`t:❑ 7.t"SED OIL Li 10.h 54IA\OL 44ob ❑ 11.OTHER`ON-PETROLEU0 S eciN* IV, TANK CONSTRUC'T'ION TYPE OF TANK I.SINGLE WALL ❑ z.DO5LE WALL [195.UNKNO«1 443 PRIMARY CONTAINMENT Ll 1.STEEL Cg'3.FIBERGLASS ❑ 6.INTERNAL BLADDER 144 ❑ 7.STEEL-INTERNAL LINING ❑ 95.L'NKX0\k1 ❑ 99.OTHER (Specify): 4"a SECONDARY CONTAINMENT ❑ 1.STEEL -1:13.FIBERGLASS ❑ b.E.\7ERIOR SIEMBRANE LINER 1E 7.1ACKETED 44` ❑ 90.;90NE ❑ 95,t;NKNOWN ❑99.OTHER(S ify): 1154 OVERFILL PREVENTION I.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT 3.FILL Tun s)4L.T-or•F VALVE 45 2. (] a,TANK MEETS REQITIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION f UIPyIENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION I.51NGLE-WALLED ❑2.DOUBLE-U'ALLED ❑99.OTHER 450 SYSTEM_TYPE ❑ I.PRESSURE ❑ z.GRAVITY ❑ 3.CONVENTIONAL S(:CTION ❑ 4;SAFE SE_°CTION P CC §'-656(aK3)) 08 PRIMARY COTTAINNIENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE Lj 19.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.l;\KNO%'.•1 ❑ 99.OTHER(Specil�•): 1684 SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464b CI 90,NONE ❑ 95,UNKXOWN ❑ 99.OTHER(Specif�): 164` P1P)NURBINE CONTAINM)=N7 SUMP TYPE ❑ 1.SINGLE WALL ❑ z.DOUBLE WALL C190.NONE 464da GT VI,VENT,'VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUC I VEv7 PRIMARY CONTAINMENT U I,STEEL 0 a.FIBERGLAss 10.RIGID PLASTIC ❑ 90.NON 99.OTHER(Sp ) 464e 464.1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FISERGLASS 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER I Spec _) 464 46tfI VR PRIMARY CONTAINMENT Lj 1.STEEL 4.FIBERGLASS 7 10.RIGID PLASTIC ❑ 90.NON' 99.OTHER(Spec fy') 04L 464_,I VR SECONDARY CONTAINMENT ❑ 1.STEEL Q 4.FIBERGLASS 10.RIGID PLASTIC 90.NONF ❑ 99.OTHER(Spc fy) 464e 4FAb I vEN'T PIPING TRANSITION SUMP TYPE I.SINGLE WALL Ll 2.DOL"BLE FALL ❑ 90,NON 4641 RISER PRIMARY CONTAINMENT Lj 1.STEEL Li 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONIE ❑ 99.OTHER(S f;•) 1t4�64 RISER SECONDARY CONTA1?\NIENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NON( ❑ 99.OTHER(Sp fy) 4641, 461kl FILL COMPONENTS INSTALLED [31.SPILL-aTtKET El3.STRIKER PLATE.BOTTONI PROTECTOR-1:14. ONT Uri\IENT SUMP 4514 c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ITJ 2,DOUBLE WALL 0 3.NO DjSPENSERS ❑ 90 NONE 169, CONSTRUCTION MIATERIAL ❑ 1.STEEL ❑ a_FIBERGLA SS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(5 cif. 16w,-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION' ❑ z.SACRIFICIAL ANODES) ❑ 4.IMPRESSED CURRENT ❑ 6,ISOLATION 449, IX. APPLICANT SIGNATURE CERTIFICATION; 1 Certify that this CAST system is compatible with the harArdous substance stored and that the information provide herein is true,aecurete, and in f0m liance with Jegal requirements, 470. DATE APPLICANT 51ONATIJRE f "�] F?LI. -q1iv' / 6 1 471' APPLICANT TITLE 172 APPLICANT NAME(Print)`,L /11A !° A UPCF UST-0-I/Z Rev.()ZfZ007)