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J UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK ' S( OPERATING PERMIT APPLICATION-TANK INFORMATION(one form pa usT) TYPE OF ACTION (Check one item only. For an UST pemtanent clos me or removal,complex only this suction and Se4x m 1.II,III,IV and IX below) ❑ 1.NEW PERMIT 913.RENEWAL PERMIT [15.CHANGE OF INFORMATION 430 13 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4"a I DATE EXISTING UST DISCOVERED: 430b V FAEII.ITY INFORMATION FACILITY ID#(Ag=W Use Only) l BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Busiam As) 1 -1- 1 1 ,317 A61 3 L.ar✓.<s Sea C+tiL.•4fo-lv v BUSINESS SITE ADDRESS ► CITY to ava/ S rem fa S ` TANKDESCRIPTIN TANK ID#. �i/1 � -� 4-42 TANK MANUFAC`rURER 433 TANK CONFIGURATKLl4:Tiffs TANK IS 434 I.A STAND-ALONE TANK K� ❑2.ONE IN A COMPARTMENTED UNrr. comokb on pw roreacb commumw inftunk DATE US'('SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 - :`<III TANK;#1ANDCONTIFNTS TANK USE I&MOTOR VE mCLE FETIrCq IG._ ❑ lb.MARINA FUELING ❑ la AVIATION FUELING 439 3.CBE MJCAL PRODUCT kAl3E Cl 4.HAZARDOUS WASTE(Ladadet Used Dail) ❑5.EMERGENCY GENERATOR FUEL[INC 12291-Xc)] ❑6.OTHER GENERATOR FUEL ❑95.UNKNOWN ❑".OTHER( ): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ la MMORADE UNLEADED PC Ib.PREMIUM UNLEADED 440 ❑3.DIESEL ❑ 5.JET FUEL ❑6.AVIATION GAS 918.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 440a NON-PETROLEUM:❑ 7.USED OI 10.ETHANOL 13 11.OTHM NON-PETROLEUM 440b . ,. ;: IV=TANIt.CO1�T�TRIICTIQN . -, TYPE OF TANK 0 1.SINGLE WALL 2.DOUBLE WALL El 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL Ul 3.FIBERGLASS ❑6.INTERNAL BLADDER 444 ❑7.STEEL+INTERNAL LINING ❑95.UNKNOWN ❑99.OTHER S 444a SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER ❑ 7.JACRtTED 445 ❑90.NONE 95.UNKNOWN ❑99.OTHER 445a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT • •3.FILL TUBE SHUT-OFF VALVE 452 ❑4.TANK MEETS REQUIREMENTS FOR EU31PTION FROM OVERFILL.PREVENTION EQU1P1alEbTT PIPING CONSTRUCTIONI.SINGLE-WALLED I DOUBLE-WAILED 99.OTH M q6p SYSTEM TYPE 1.PRESSURE 2.GRAVITY 3.CONVENTIONAL SUCTION 0 4.SAFE SUCTION 123 CCR ao)) 458 PRIMARY CONTAINMENT i.STEEL 4.FIBERGLASS 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE 95.UNKNOWN ❑99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑8.'FLFE03LE 0 10.RIGID PLASTIC 464b ❑90.NONE 95.UNKNOWN ❑W.OTHER(Specify): 464c PIPIQGfrUR INE CO AINM[ENT SUMP TYPE Of I.SINGLE WALL 2.DOUBLE WAIL 13 90.NONE 4644 . �YAYORRECOYERY t.x�)�a4v+� iSRR.I FI +IEIIE __ C0�5TRUCTI(31� VENT PRIMARY CO AINAIEI iT 1.STEEL K 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464a _we46k1 VENT SECO-MARY OONTAINMENT 13 1.STEEL El 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 13 99.OTHER(SpcL*) 464E 464fl VR PRIMARY CONTAINMENT 0 I.RiM7 IKTFmERGLAss 13 10:RIGID PLASTIC 090.NONE0 99.OTHER(Specify) 464g VR SECONDARY CONTAINMENT ❑ L STEEL El 4.FIBERGLASS E3 l0.RIGID PLASTIC90.NONE0 99.OTHER(Specify) 464b ta 46461 VENT PIPINGON SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 464L RISER PRIMARY CONTAINMENT 14 1.STEEL 13 4.FIBERGLASS U 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464j 4647 RISER SECONDARY CONTAINMENT E3 I.STEEL El 4.FIBERGLASS E3 10.RIGIDPLASTIC 90.NONE E3 99.OTHER(Specify) 464k FILL COMPONENTS INSTALLED M 1.SPIL BUCKET ArlSTRUMPLATUBOTTOMPROTBCTOR Ej 4.CONTAINIENT SUMP _. 45 464k1 Vb UNbER"D COl�l CONSTRUCTION TYPE a 1.SINGLE WALL ❑2.DOUBLE WALL ❑3.NO DISPENSERS ❑90. 469a CONSTRUCTION MATERIAL Q T.STEEL D 4.FIBERGLASS 19 10.RIGID PLASTIC Q99.OTHER( 469bc COMORON PROTECTION STEEL COMPONENT PROTECTION ❑2.SACRIICIAL ANODE(S) ❑4.meREssm CURRENT LSOLA71ON 448. IX. APPUCAW GNAT�TRE. CERTIFTCATION:I ewdfy that thh UST system 6 camp d&b wI&the yasudos a subsbm sond sad that the InformationrovNed herein and In&JI P ' nix' APPLICANT SIGNATURE DATE 470. APPLICANT NAME 471. a72 `r tM A-t-- �D c t�-- APPLICANT TI TLE 1 E i , UPCF UST-B-1/2 Rev.(1212007)