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O- IFIED PROGRAM CONSOLIDATED FO <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION !oncivnr per u <br /> TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11,111,IV,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 /> DATE UST PERMANENTLY CLOSED: 430a. DATE EXISTING UST DISCOVERED: 4306. <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) - - 1. <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> BUSINESS ITE ADDRESS 103. CITY 104. <br /> _27 AJ TPAW Vv <br /> II. TANK DESCRIPTION <br /> TANK ID# 432. TANK MANUF TURER 433. TA K CONFIGURATION:THIS TANK IS 434. <br /> �+ 1.A STAND-ALONE TANK Complete one page for each <br /> Q 6 IQ `�/� ❑ 2.ONE INA COMPARTMENTED UNIT compartment in the unit. <br /> DATE UST SYS M ALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. <br /> l 1 <br /> III. TANK USE AND CONTENTS <br /> TANK USE la.MOTOR VEHICLE FUELING ❑ lb.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 /> .. ............._......._............._............................__..._..._.............._............._.._..._.__....._............_....._...._..........__......_..... ................. <br /> CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED )8 1b.PREMIUM UNLEADED 440. <br /> ❑ 3.DIESEL 0 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440a. <br /> ................................................................................................................._..._......................-----............................_.-........_._............................._ ............._.._...__........................................_....................................... <br /> _... <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443. <br /> ......._......................................................-....................._......._........................_..._._............_.._................__......__............_...__......_........._..._..._.................._........_........__._.............._............................................._....................................................._......_.. <br /> PRIMARY CONTAINMENT O 1.STEEL 3.FIBERGLASS O 6.INTERNAL BLADDER 444. <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN 0 99.OTHER(Specify): 444a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. <br /> ❑ 90.NONE 95.UNKNOWN ❑99.OTHER(Specify): 445a. <br /> ---....._....._............ - ..............................................................................................................._.........._ ---......._..__......_......._....._...__._............._......_._..............................._. .................................._.............. <br /> OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT 19 3.FILL TUBE SHUT-OFF VALVE 452. <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUC /WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION 0 1.SINGLE WALL 2.DOUBLE WALL ❑ 99.OTHER 460. <br /> SYSTEM TYP. .... ............. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. <br /> ❑ 90.NONE �95.UNKNOWN ❑ 99.OTHER(Specify): 464a. <br /> --..............._...................._...__................................................_.................. _._........_............................_..._...............25._.......-.._._......._....._...._..................-................_._..... ....... .............._..................... <br /> ._............... <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC a6ab. <br /> 90 NONE 95.UNKNOWN 99 OTHER 464c. <br /> _............................................_....__.........._�--....:.._....---........__......._...........­ .._-.........._....................._........................_0............:..........................._�Sp..*-, ...... ..............._.........................._.......... <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL 0 2.DOUBLE WALL O 90.NONE qMd <br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> 464e. <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): a64el. <br /> ...................._._._.__.._..._._._._...._....--.--......_........_._.__...........__.._................. __ .................................. _......................._...._........_.._.__...._..._......................_........................_.......__............._ ........_.............._..... _ ........._........................__.._......_............. ....464f. <br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464fl. <br /> ........................_..........._......._.__..............__............._..............._........._.............................................._............._._........ ......._......----......_..._..--.....-......._.-.__..................... ._...._I......._... <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4664 <br /> 4 B <br /> _._ <br /> VR SECONDARY CONTAINMENT_....................0....1.STEEL 0 4.FIBERGLASS__._._0 10.RIGID PLASTIC ❑ 90.NONE O 99.OTHER(Specify): 46 hi. <br /> VENT PIPING TRANSITION SUMP TYPE O 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4M` <br /> ..............__._._._....._....._.__._...---.._._.. ---._.._...__............................._...._..........................................................................._.................__..__......_......_..............._....__............-.................._...........-......_.._....._..........................................................................._..._.................................._....-.........._..._......................_.......... <br /> RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46411. <br /> ........................_.........................._............._..._...._.._.._................-....._..-._....._..._..................-_..........__..._......................................................._..................................._.._.._........_.._..__.._..............__.._._....-----...........---...... 464k. <br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.TH RG ASS ❑ 10.RIGID PLASTIC O 90.NONE ❑ 99.OTHER(Specify): 464k1. <br /> _..__..............._.._.......-...--............----........._....._..................................................................................._....................._......... ..._._....._..._-..._....... .............._......_............._-............._......................._..............._........................................._........ <br /> FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a-c. <br /> UNDER DISPENSER CONTAINMENT (UDC) <br /> CONSTRUCTION TYPE 1.SINGLE WALL 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a. <br /> ................_...................._.._...._.._. __.._......_----._.............._..................................._......_.......-..._.........................................................................._.................__..._._..........._._......_....._...----......----._._.................._........_...._.............._.................._._..................4......_...... <br /> CONSTRUCTION MATERIAL O 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC O 99.OTHER(Specify) 4696. <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION O 2.SACRIFICIAL ANODE(S) 0 4.IMPRESSED CURRENT 0 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, <br /> accurate,andAjyfuIVm liance with legal requirements. <br /> APPLICANT SIGNATURE DATE /A 470. <br /> APPLICANT NAME(print) �y 471' APPLICANTTITLE 472' <br /> UPCF UST-13 Rev.(12/2007)-1/2 �l www.unidocs.org <br />