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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per USS TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections t,[I,[[l,[V,and IX below) 430 ❑ 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: " DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agencv Use Only) BUSINESS NAME Same as FACILITY NAME or DBA-Doing Business As) 3 c6'M�r URZ � BUSINE �1 t E AD ESS �� -r( '/ / 103 CITY J Q�t Q � toa II.TANK DESCRIPTION �'1 c�r TANK t om; y � 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK 1S 438 (( 1.A STAND-ALONE TANK ❑2.ONE W A COMPARTMENTED UNrr.. !! •l Co teonepagcforeachqW%Vrtmemizktheunk. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 433 M.TANK USE AND CONTENTS TANK USE Vla.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Iaclodes uud Oil) ❑ 5.EMERGENCY GENERATOR FUEL W ❑ 6.OTHER 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: Ia.REGULAR UN ❑ 1c.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 L ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S ); 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ i 1.OTHER NON-PETROLEUM(Specify), 440b IV.,TANK CONSTRUCTION TYPEOFTANK 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL 12k 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION I.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.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 W DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE W 1.PRESSURE ❑ 2 GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION In CCR§2636(ax3)) 458 PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL E&4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4Ub ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify), 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL C&2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464c 464el VENT SECONDARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 4640 VR PRIMARY CONTAINMENT 10 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464 1 VR SECONDARY CONTAINMENT 1.1.STEEL ❑ 4.FIBERGLASS ❑ 1Q RIGID PLASTIC ❑ 9o.NONE ❑ 99.OTHER(Specify) 464h 464ht VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL 112.DOUBLE WALL ❑ 90.NONE 464L RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464j RISER SECONDARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ t0.RIGID PLASTIC ❑ 9o.NONE ❑ 99.OTtiER(Sify) { pec464464'1 4641 FILL COMPONENTS INSTALLED 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL (a,2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ L STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696{ VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448- M APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,aestitate, and in full compliance with legal requirements. APPLICANT SIGNATURE DATE -� 470. APPLICANT NAME(print) ©� 471. 4n_APPLICANT T LE d�/ UPCF UST-8-1/2 Rev.(12/2007)