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UNIFIED PROGRAM CONSOLIDATED FORM t UNDERGROUND STORAGE TANK ��J� OPERATING PERMIT APPLICATION-TANK INFORMATION One form Per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,Il,II1,IV,and IX below) 430 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ S.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE E3 7.UST PERMANENT CLOSURE ON SITE El 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DLSCOVERED: 430b FACILITY ID# A { gency Use OntJ) t BUSINE NAME( as FACILITY NAME or DBA-Doing Business As) 'Q 3 OeajO-h L-4:4-fIF- Co f sus ss NM ADDREssuj IA�� .0- t 3 CITE_O� d A� ,P f to II';TA1!iR ItESiCR `iON. TANK ID# 432 TANK MANUFACTURER 433 WANK CONPIOURATION: THIs TANIt:13 434 I.A STAND-ALONE TANK O 2.ONE IN A COMPARTMENTED UNIT. one tarearb is Doer. DA.TE USTSY STALLED 43S T CAP IN A1,LONS 436 NUMBER OF COMPARTMENTS IN THE UNIT' 437 u TANK USE MLIa.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(bdoda Used Oil) ❑ S.EMERGENCY GENERATOR FUEL p85C 125281.5(e)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑".OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ le.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 PC3.DIESEL ❑5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 440a NON-PETROLEUM: 7.USED OIL 0 10.ETHANOL 11.OTHER NON-PETROLEUMS 440b TYPE OF TANK 1.SINGLE WALL 2.DOUBLE WALL 9S.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL U 3.FIBERGLASS Q 6.INTERNAL BLADDER 444 7.STEEL+INTERNAL LINING Q 95.UNKNOWN 13 99.OTHERpecift 444a SECONDARY CONTAINMENT 1.STEEL CIL3,FIBERGLASS S 6.EXTERIOR MEMBRANE LINER 7.JACKETED 445 13 90.NONE 9S.UNKNOWN 1399.OTHER S 445a OVERFILL PREVENTION L AUDIBLE&VISUAL ALARMS 0 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT pRUPVC'I`I Vt�A PII l4 C�DNS lI 1170N PIPING CONSTRUCTION I.SINGLE-WALLED Q 2.DOUBLE-WALLED 99>OTHBR 460 SYSTEM TYPE IL L PRESSURE 2.GRAVITY Q 3.CONVENTIONAL SUCTION El 4.SAFE SUCTION 23 CCR 263 a 3 75 PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 8.FLEXIBLE 10.RIGID PLASTIC 464 ❑90.NONE 95.UNKNOWN ❑99.OTHER(Specify): 464& SECONDARY CONTAINMENT 0 1.STEEL4.FIBERGLASS U L FLEXIBLE U 10.RIGID PLASTIC 464b El90.NONE ❑95.UNKNOWN ❑99.OTHER(Specity): 464c PIPINdriumME CONTAINMENT SUMP TYPE 1.SINGLE WALLC1 2.DOUBLE WALL 90.NONE 4644 VENT PRIMARY CONTAINMENT U 1.STEEL J5 4,FIBERGLASS U 10.RIGID PLASTIC 90.NONE arum(Specify) 464e 464et VENT SECONDARY CONTAINMENT 1.STEEL Ia 4.FIBERGLASS U 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT %El.STEEL E3 4.FIBERGLASS 0 10.RIGID PLASTIC 13 90.NONE 0 99.OTHER(Specify) 4645 VR SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 0.RIOID PLASTIC 90.NONE 99.OT HER(Specify) 464b 4664L VENT PIPING TRANSITION SUMP TYPE I.SINGLE WALL 2.DOUBLE WALL 90.NONE 464i. RISER PRIMARY CONTAINMENT 1.3TEEL 4.FIBERGLASS 10.RIGIDPLASTIC 90.NONE. 99.OTHER(SpedQ,) 464j 464 I RISER SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET X1STRIKERPLATEMOTTOMPROTECTOR 4.CONTAINMENT SUMP 451" dal �iRDs4r �r?tsira4 r3Alfflhuml .1 - .., CONSTRUCTION TYPE L SINGLE WALL ❑2.DOUBLE WALL ❑3.NO DISPENSERS 13190.NONE 469+ CONSTRUCTION MATERIAL L STEEL 4.FIBERGLASS 10.RIGID PLASTIC Q99.OTHER 469bc VIM: C'IIR( dNCY!'. ktll►N STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑4.IMPRESSED CURRENT 6.ISOLATION 448. Et APPLIC1ilNT RStLC!fA'1' TItE CERTIFICATION:7 eerrdty this UST aymam Is a mp table with the hmniew aahMaaee sepred nerd fist the lafermattiea provWed herein b tree,accurate, and� wNh alrenaeats. APPLICANT SIGNATURE DATE // �+ 470. APPLICANT NAME(print) 471 APPLICANT TITLE s /� 472. UPCF UST-B-172 Rev.(12fZt107)