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MN UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK 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 I,II,III,IV,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: 430a DATE EXISTING UST DISCOVERED: 430b I.FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business Ars) s .5 C4 STD BUSINESS SITE ADDRESS to3 1 a 9 0 N M l,v s "'4 r,I ?�CA G `°° II.T ify DESCRIPTION TANK ID# 3CJ432 T A/ 433 T }//�� Y TA ONFIGURATION: THIS TANK IS 434 l A 0,�� `' I 1 Al C L//��. STAND-ALONE TANK JJJ 1 ❑2.ONE IN A COMPARTMENTED UNIT. Complete one a for each com artmem in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 431 III:TANK USE A$4 CONTENTS TANK USE D11a.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE. ❑ 4.HAZARDOUS WASTE(Includes Used Oil) [15.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] C16.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99 OTHER(Specify): 439a CONTENTS PETROLEUM: la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED [IIb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL I I.OTHER NON-PETROLEUM(Specify): 4406 M ;TANK.CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTER NAL LWING ❑ 95.UNKNOWN ❑ 99.OTHER (S ci ): 444a SECONDARY CONTAINMENT ❑ 1.STEEL FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 11 90.NONE Q 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION ❑ 1.AUDIBLE&c VISUAL ALARMS 2.BALL FLOAT .FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODIICT.!_WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED .DOUBLE-WALLED ❑99.OTHER 46 SYSTEM TYPE I.PRESSURE ❑ 2.GRAVITY ❑3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(ax3)] 458 PRIMARY CONTAINMENT ❑ I.STEEL FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL EK FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ I.SINGLE WALL ❑2.DOUBLE WALL ❑ 90.NONE 4644 VI:VENT, OR RECOVERY(yR).ANDRISER y kILL PIPE PIPING CONSTRUCTION . VENT PRIMARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464e VENT SECONDARY CONTAINMENT ❑ 1.STEEL 6r4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.O 444 THER CS(Specify) 64E VR PRIMARY CONTAINMENT ❑ 1.STEEL [y4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 4 99.OTHER(Specify) 464g VR SECONDARY CONTAINMENT ❑ L STEEL gr4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90 4 .NONE ❑ 99.OTHER(Specify) 46411 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 464hi RISER PRIMARY CONTAINMENT 4641. ❑ 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE U 99.OTHER(Specify) 464j RISER SECONDARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 464 I ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 4I I FILL COMPONENTS INSTALLED I.SPILL BUCKET 3.STRIKER PLATEBOTTOM PROTECTOR 4.CONTAINMENT SUMP 451skc VII.UNDER DISPENSER C0NTAINMENT.(L1DC),. CONSTRUCTION TYPE 1.SINGLEWALL Ll2.DOUBLE WALL ❑3.NO DISPENSERS ❑ 90.NONE 469. CONSTRUCTION MATERIAL ❑ 1.STEEL FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99 ER(Specify) 469b< VIII. CORROSION;PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. 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 in full compliance with legal requirements. APPLICANT SIGNATURE LG�� DATE (r. 12 •I Z 4�0. APPLICANT NAME(print) 471' APPLICANT TITLE 472. UPCF UST-B-1/2 Rev.(12/2007)