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MN �iI21Itf <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) <br /> TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,III,N,and IX below) 430 <br /> ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL <br /> ST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 430b <br /> ATE U,. .., _. <br /> I.:FACILITY"INFQRMATION <br /> FACILITY ID#(Agency Use Only) I <br /> BUSINESS NAME(Same as FACILITY NAME r DBA-Doin Business As) 3 <br /> �v®e2 'Crop � "L1-/QQQ <br /> BUSINESS SITE ADDRESS I0 <br /> 3 CITY <br /> o�Q t7 �N • M A!N S"f' loa <br /> II TANKDESCRIPTION <br /> TANK ID# 432 433 TANK CONFIGURATION:THIS TANK IS 434 <br /> TL 05- nor r❑11.A STAND-ALONE TANK <br /> 1 CCJJ (� I Lid'1•ONE IN A COMPARTMENTED UNIT. <br /> Complete one pay for each compiotment in the unit. <br /> DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 <br /> 2 . <br /> III:TANK USE AND,CONfENTS7777 <br /> TANK USE la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc.AVIATION FUELING 439 <br /> ❑ 3.CHEMICAL PRODUCT STORAGE. ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)) <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a <br /> CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ la MIDGRADE UNLEADED 9-16.PREMIUM UNLEADED 440 <br /> ❑ 3.DIESEL ❑ 5.TET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 <br /> IV :;TANK CONSTRUCTIQN <br /> TYPE OF TANK ❑ 1.SINGLE WALL F2.DOUBLE WALL ❑ 95.UNKNOWN 443 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER. (Speci ): 444a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 <br /> 1190.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a <br /> OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS 02.BALLFLOAT FILL TUBE SHUT-OFF VALVE 452. <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V; PRODUCT!_WASTE PIPING CONSTRUCTION, <br /> PIPING CONSTRUCTION ❑I.SINGLE-WALLED 9<DOUBLE-WALLED ❑99.OTHER 460 <br /> SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4 <br /> SECONDARY CONTAINMENT ❑ 1.STEEL FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464a <br /> VI:VgNT,VAPOR,RECOVERY(VR}AND:RISER/TILL PIPE"PIPING CONSTRUCTION. <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL Ur4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464e <br /> VENT SECONDARY CONTAINMENT 464e1 <br /> ❑ I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464f <br /> VR PRIMARY CONTAINMENT 464n <br /> ❑ 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 <br /> 464 l <br /> VR SECONDARY CONTAINMENT <br /> ❑ L STEEL PT FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE [3 99.OTHER(Specify) 464h <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL DOUBLE WALL ❑ 90. ONE <br /> 464hl <br /> 464i. <br /> RISER PRIMARY CONTAINMENT El1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464j <br /> 464'1 <br /> RISER SECONDARY CONTAINMENT <br /> ❑ 1.STEEL ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NO ❑ 99.OTHER(Specify) 464k <br /> FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATEBOTTOM PROTECTOR 4. 1 I <br /> CONTAINMENT SUMP 4564kc <br /> VII .UNDER DISPENSER CONTAINMENT.(ITDC) <br /> CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696 c <br /> VIIL. CORROSION"PRUTECTION " <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION:I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, <br /> and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE , DATE0�- 12L , <br /> II 470. <br /> APPLICANT NAME(print) 971' APPLICANT TITLE 472. <br /> UPCF UST-B-1/2 <br /> s <br /> $^ '7 fn 7 Rev.(12/2007) <br /> e ti <br />