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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 1,11,111,IV,and IX below) 430 1.NEW PERMIT Ej 3.RENEWAL PERMIT [:1 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 0 7.UST PERMANENT CLOSURE ON SITE El 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4"a I DATE EXISTING UST DISCOVERED: 430b L FACILITY INFORMATION FACILITY ID#(Agency Use Only) I BUSINESS NAAW(Same as FACCILITY NAME or RPA-Doing Business As) 3 -7 ITY 104 BUSINESS SITE ADDRESS k IL TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 M -ALONETANK Qy\ A STAND 'AA 2.ONE IN A COMPARTMENTED UNIT. Complete me paLe fix each compmtnerd in the uifit. DATE UST SYSD11�STALLED 435 TANK CAP ITY IN LONS 436 NUMBER OF COXPARTMENTS IN THE UNIT 437 100V Z. 111.TANK USE A"CONTENTS , TANK USE gr Ia.MOTOR VEHICLE FUELING El 1b.MARINA FUELING [I Ic.AVIATION FUELING 439 [-1 3.CHEMICAL PRODUCT STORAGE 4.HAZARDOUS WASTE(Ewludes Used Oil) [_3 5.EMERGENCY GENERATOR FUEL EHSC�25281.5(c)l 0 6.OTHER GENERATOR FUEL 95.UNKNOWN [1 99.OTHER(Specify): 439a CONTENTS PETROLEUM: 0 Ia.REGULAR UNLEADED 0 Ic.MIDGRADE UNLEADED 0 Ib.PREMIUM UNLEADED [1 3.DIESEL 0 5.JET FUEL 0 6.AVIATION GAS 0 8.PETROLEUM BLEND FUEL 0 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:0 7.USED OIL 0 10.ETHANOL 11.OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION TYPE OF TANK [1 1.SINGLE WALL 0'2.DOUBLE WALL [1 95.UNKNOWN 443 PRIMARY CONTAINMENT 0'I.STEEL 0 3.FIBERGLASS [:1 6.INTERNAL BLADDER 444 0 7.STEEL+INTERNAL LINING [1 95.UNKNOWN 0 99.OTHER (Specify): 444a SECONDARY CONTAINMENT [1 1.STEEL gr3.FIBERGLASS 0 6.EXTERIOR MEMBRANE LINER F-1 7.JACKETED 445 [1 90.NONE 0 95.UNKNOWN [199.OTHER(Specify 445a OVERFILL PREVENTION [1 1.AUDIBLE&VISUAL ALARMS [1 2.BALL FLOAT jT1.FILL TUBE SHUT-OFF VALVE 452. 0 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 0 1.SINGLE-WALLED 0'2.DOUBLE-WALLED 0 99.OTHER 460 SYSTEM TYPE 0 1.PRESSURE [1 2.GRAVITY [1 3.CONVENTIONAL SUCTION [1 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458 PRIMARY CONTAINMENT Z 1.STEEL 0 4.FIBERGLASS El 8.FLEXIBLE [1 10.RIGID PLASTIC 464 [1 90.NONE [1 95.UNKNOWN [1 99.OTHER(Specify): 464a SECONDARY CONTAINMENT [1 1.STEEL 2r4.FIBER-GLASS [1 8.FLEXIBLE 0 10.RIGID PLASTIC 464b [1 90.NONE [1 95.UNKNOWN [] 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE Pr 1.SINGLE WALL 0 2.DOUBLE WALL 90,NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 21I.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC [1 90.NONE 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT 0 1.STEEL [1 4.FIBERGLASS [3 10.RIGID PLASTIC [:) 90.NONE 99.OTHER(Specify) 464f 464fl VR PRIMARY CONTAINMENT QrLSTEEL [1 4.FIBERGLASS [:1 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 464g 464gl VR SECONDARY CONTAINMENT 1.STEEL [1 4.FIBERGLASS [3 10.RIGID PLASTIC 0 90.NONE [1 99.OTHER(Specify) 464h 464hI VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 0 90.NONE 464i. RISER PRIMARY CONTAINMENT 1.STEEL [1 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE [1 99.OTHER(Specify) 464j 464jI RISER SECONDARY CONTAINMENT El 1.STEEL [1 4.FIBERGLASS [1 10.RIGID PLASTIC 0 90.NONE [1 99.OTHER(Specify) 464k 464kI FILL COMPONENTS INSTALLED Er 1.SPILL BUCKET iff 3.STRIKER PLATE/BOTTOM PROTECTOR Rr4.CONTAINMENT SUMP 45la-c VH UNDER DISPENSKR CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL [1 2.DOUBLE WALL [1 3.NO-DISPENSERS 90.NONE 469a CONSTRUCTION MATERIAL 1.STEEL Iff 4.FIBERGLASS 0 10.RIGID PLASTIC El 99.OTHER(Specify) 469b-c VIII,CORROSION PROTECTION STEEL COMPONENT PROTECTION 0 2.SACRIFICIAL ANODE(S) El 4.IMPRESSED CURRENT [3 6.ISOLATION 448. IX "PLICANT 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 compliaikce with legal requirements. APPLICANT SIGNATU!!�� DATE 470. APPLICANT NAME(print) 471. APPLICANT TITLE 47n2 10 KA 0(k) ri UPCF UST-B-1/2 Rev.(1212007)