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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 a UST closure or removal,complete only this section and Sections I,A III,lY and lX below) 430. 1 i ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE El 7.UST PERMANENT CLOSURE ON SITE ❑ S.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4306- DATE EXISTING UST DISCOVERED: 430b. l -`w a. :r ti a �y�{Y+ #•btr i. 7 ,fit s :l Tr- i� iy{" �t'[ihti �1 ~1. � : .�'l•�Y�� f��.u. J.� �?",",. 'L R. .t.fi r'.2n.� t �. .✓.l"a... .. ... .tt t.vs..- w ..l.}.r..,, ,1 rl....:..: :.... ...: ...;�,.:...:?,.:..r vn. ,.:-, a _ . I FACILITY ID#(Agency Use Otely) " 2,x9::.1,1 'T,.i _ BUSINESS NAME(Same as Facility Name or DBA-Doing Business.fs) 3. MCI,dba,Verizon Business BUSINESS SITE ADDRESS 103. CITY 104• 13850 N.DeVries Road Lo s di - f TANK ID$ 432. TANK MANUFACTURER 433• TANK CONFIGURATION:THIS TANK IS 434. 1 XCI7L8S ® 1.A STAND-ALONE TANK Compkteone psae for each 13 2.ONE IN A COMPARTMENTED UNIT companment in the wit X DATE UST SYSTEM INSTALLED 435- TANK CAPACITY IN GALLONS 436• NUMBER OF COMPARTMENTS IN THE UNIT 437• 1985 550 1 -M .Y t SSE ANA C?UNTENT , TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ ]b.MARINA FUELING ❑ lc.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used 01) N 5.EMERGENCY GENERATOR FUEL[HSC§25291.S(c)] C1 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN _ ❑ 99.OTHER(Specify): 439& CONTENTS PETROLEUM: ❑ 12L REGULAR UNLEADED ❑ ]c.MIDGRADE UNLEADED p lb.PREMIUM UNLEADED 440. i§ ® 3.DIESEL (:1 5.JET FUEL ❑ 6.AVIATION GAS i ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUMS c] ): 440& NON-PETROLEUM:❑ 7.USED OIL 0 10.ETHANOL ❑ IL OTHER NON PETROLEUMS 4406. TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS O 6.INTERNAL BLADDER 444. O 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify). 444a. d SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS p 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE O 95.UNKNOWN ❑99.OTHER(Specify): 445& OVERFILL PREVENTION ® 1.AUDIBLE k VISUAL ALARMS O 2.BALL FLOAT ❑ 3.FELL TUBE SHUT-OFF VALVE 451 4.TANxmmsgEQumuspmFopBxEwnoNFRomovERFiLLPREVENnONEQUWbMT f' 'J!Pir .ST PPIl�1G_CONS IICTIQN t PROD x PIPING CONSTRUCTION ❑ 1 SINGLE WALL ® 2.DOUBLE WALL ❑ 99.OTHER 460. SYSTEM TYPE ❑ 1.PRESSURE 0 2.GRAVITY ® 3.CONVENTIONAL SUCTION p 4.SAFE SUCTION[23 CCR§2 a 3)] 458. PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ® S.FLEXIBLE p 10.RIGID PLASTIC 464. 3 O 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464& 1 SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ® 8.FLEXIBLE p 10.RIGID PLASTIC 4646. ❑ 90.NONE ❑ 95.UNKNOWN p 99.OTHER S ' ): 4640. PIPINGrfURBINE CONTABYMENT SUMP TYPE 1.SINGLE w z.DOUBLE WALL 0 90.NONE VENT PRIMARY CONTAINMENT p 1.STEEL. ® 4.FIBERGLASS O 10.RIGIDPLASTIC p90.NONE .O 99.OTHERspecify): 46 8i VENT SECONDARY CONTAINMENT ❑ I.STEEL. ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ® 90.NONE O 99.OTHER(Specify): a464. VR PRIMARY CONTAINMENT ❑ 1.STEEL O 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify). a64$ _ 46481. VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS O 10.RIGIDPLASTIC ® 90.NONE p 99.OTHER(Specify): 464h1. VENT PIPING TRANSITION SUMP TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE RISER PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE p 99.OTHER(Specify): RISER SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ ]0.RIGID PLASTIC O 90.NONE ❑ 99.OTHER(Specify): a FILL COMPONENTS INSTALLED ® 1 SPILL BUCKET E3 3 STRUM PLATEIBOTIOM PROTECTO 4 CONTAINMENT SUMP 451a-c 4} NEW CONSTRUCTION TYPE ❑ 1.SIN(KE WALL ❑ 2.DOUBLE WALL ® 3.NO DISPENSERS ❑ 90.NONE 469L j CONSTRUCTION MATERIAL ❑ 1.STEEL p 4.FIBERGLASS O 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4690- TYCO ". STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANDD S O 4.RAPRESSED CURRENT C3 6.ISOLATION 448• x g 1A777 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 Itizal re uirements. APPLICANT SIGNATURE DATE 9/3/2009 470' APPLICANT NAME(print) Todd Harris 471' APPLICANT TITLE Regional Environmental Manager 4n" UPCF UST-B Rev.(12/2007)-I!Z www.unidocs.org