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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK f (l Q9 OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections L IL 111,X and LX below) 430. ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION El 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE El 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4i0z 1 DATE EXISTING UST DISCOVERED: 4306. I. FACILITY INFORMATION FACILITY ID#(Agency Use Onl}) - - 1 BUSINESS NAME(Same as Facilin-Name or DBA -Doing Bush ess AS)AIJ 3' 1 BUSINESS SITE ADDRESS 10= BUSINESS SITE CITY 1a4. 2' Cfor U. TANK DESCRIPTION TANK ID# 43' TANK MANIIFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 / dQ 1.A STAND-ALONE TANK Complete one pave for each (.� ❑ 2.ONE IN A COMPARTMENTED UNIT compamnent in theunn. DATE UJSj 5YSTEM NST LED --4k. TAN CAPACITY IN GALLONS 436- NUMBER OF COMPARTMENTS IN THE UNIT 437. III. TANK USE AND CONTENTS TANK USE a.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCE`GENERATOR FUEL[HSC 525281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439& CONTENTS PETROLEUM: ❑ la.REGULAR U'NLE.ADED � lc.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440' [:13.DIESEL 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM_ BLEND FUEL _❑ 9.OTHER PETROLEUM(Spccify): a40a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETH.A.NOL 4406. ❑ 11.OTHER NON-PETROLEUM(Specify): IV. TANK CONSTRUCTION 443. TYPE OF TANK ❑ L SINGLE WALL 0'2.DOUBLE WALL [195.UNKNOWN _--- - - PRIMARY CONTAINMENT {a L STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL-INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.-OTHER(Specify): 444a SONDARY CONTAINMENT [IL STEEL FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. EC [390.NONE [:] 95.UNKNOWN ❑99.OTHER(Speci : 445a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT 1&3.FILL TUBE SHUT-OFF VALVE 452 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL REVENTION E UIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL W2.DOUBLE WALL ❑ 99.OTHER 4R SYSTEM TYPE 1.PRESSURE 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4 SAFE SUCTION[23 CCR 263 _ 6(a)(3)] 458. PRIMARY CONTAINMENT ❑ 1.STEEL [jr4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464' El90.NONE C] 95.UNKNOWN ❑ 99.OTHER(Specify): _;64a_ SECDARY CONTAINMENT [31.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. ON ❑ 464c. 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): PIPINGIIURBINE 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 1.STEEL 4.FIBERGLASS El 10.RIGID PLASTIC [190.NONE ❑ 99.OTHER(Specify): 464ee1 -- 464E VENT SECONDARY CONTAINMENT Q�11.STEEL ❑ 4.FIBERGLASS E] 10.RIGID PLASTIC 90.NONE E399.OTHER(Specify): 464fl. VR PRIMARY CONTAINMENT IL 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464SI. 464h VR SECONDARY CONTAINMENT 1.STEEL LJ 4.FIBERGLASS ❑ ]0.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 464hl. -- __'V9 - 4641. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLEWALL ❑ 2.DOUBLE WALL 90.NONE - EL El ----- --[3E]-- ----------- 464 RISER PRIMARY CONTAINMENT 0 .STE4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify): RISER SECONDARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 46464kk FILL COMPONENTS INSTALLED 5r 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c. VII. UNDER DISPENSER CONTAINMENT(UDC) CONST_RU_CTION TYPE _ 1.SINGLE 1VALL _�2.DOUBLE R'.ALL ❑3.NO DISPENSERS 90.NONE - 469a --'-- 4696. CONSTRUCTION MATERIAL GKI.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) ,- VIII. CORROSION PROTECTION - STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION DL APPLICANT SIGNATURE CERTIFICATION: I certify,that this UST system is compatible with the hazardous substance stored and that the information provided herein is"'true,; accurate,and jpjull compliance with legal requirements. 479 APPLICANT SIGNATURE DATE APPLICANT NAME(print) APPLICANT TITLE UPCF UST-B Rev.(12/2007)-1/2 wwwamidocs.org Effective 01 (d 1\ ((