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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK i OPERATING PERMIT APPLICATIONINFORMATION (One form per UST) TYPEOFACTION (Check one item only. For a USTclosure or removal,compkto only this section andSections 1,11,111,IV,and-mbelow) 430. rl 1.NEW PERMIT 0 3.RENEWAL PERMIT [I 5.CRANGE OF INFORMATION Q 6.TEMPORARY LIST CLOSURE 0 7.LIST PER A ENT CLOSURE ON SITE 0 8.UST RB40VAL DATE UST PERMANENTLY CLOSED: 43N. :1 DATE EXISTING UST DISCOVERED. 439b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) ? EMnEnS Nm-mmmmmm- mm MEM -k 11111.1291ilw1f 17 -1 +"MI &W I NjftnAm BUSINESS SITE ADDRESS 1501 NORTH JACK TONE ROAD TANK ID# 432. TANK MANUFACTURER • 6 OWENS CORNING i Ail Is K CAPACITY IN GALLONS -4 3 6.. ;; NUMBER OF COMPARTMENTS IN THE UNIT C3-7. 12,000 1 UL TANK USE AND CONTENTS TANK USE N In.MOTOR VEHICLE FUELING D Ill.MARINA FUELING E3 Ic.AVIATION FUELING 439. [3 3.CHEMICAL PRODUCT STORAGE 0 4.HAZARDOUS WASTE(includes Used Oil) 0 5.EM ERGENCY GENERATOR FU EL(FiSC 025281.5(c)] 0 6.OTHER GENERATOR FUEL 0 95.UNKNOWN 0 99.OTHER(Specify): 439a. CONTENTS PETROLEUM: rl Ia.REGULAR UNLEADED 11 Ic.MIDGRADEUNLEADED 0 1h.PREMIUM UNLEADED rl 3.DIESEL 0 5.JET FUEL [1 6.AVIATION GAS 0 8.PETROLEUM BLEND FUEL El 9.OTHER PETROLEUM(Specify); 440a. NON-PETROLEUM:0 7. SED OIL 1-0.ETHANOL 0 11.OTHER NON-PETROLEUM(Specify): 440b, IV. TANK CONSTRUCTION TYPE OF TANK ■ 1.SINGLE WALL 0 2.DOUBLE WALL ■ 95.UNKNOWN PRIMARY CONTAINMENT El LSTEEL IN 3.FIBERGLASS ■ 6.INTERNAL BLADDER 0 7.STEEL+INTERNAL LINING ■ 95.UNKNOWN 0 99.OTHER(Specify): 444a. SECONDARY CONTAINMENT [I LSTEEL N 3.FIBERGLASS 0 6.EXTERIOR MEMBRANE LINER [1 7.JACKETED --,f4-5.-: 0 90.NONE 0 95.UNKNOWN 0 99.OTHER(Specify): 443L ■ OVERFILL PREVENTION 0 1.AUDIBLE&VISUAL ALARMS [3 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. 4.TANK MEETS REQUIREMENTS FOR-EXEMPTION FROM OVERFILL PR_EVE-NT1ON EqUIPMENT PRODUCT/WASTE PIPING CONSTRUCTION m1muml 2.DOUBLE WALL 0 99,OTHER 460. SYSTEM TYPE LPRESSURE 2.GRAVITY 0 3.CONVENTIONAL SUCTION C3 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458. PRIMARY CONTAINMENT 0 it4.FIBERGLASS 0 &FLEXIBLE 0 10.RIGID PLASTIC 464.' 0 90.NONE 0 95.UNKNOWN [1 99.OTHER(Specify): 464o. SECONDARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS [3 &FLEXIBLE D 10.RIGID PLASTIC 464b. Q 90.NONE 0 95.UNKNOWN E■3 99.OTHER(Stsmify). 464c. PIPING/TURBINE CONTAINMENT SUMP TYPE 0 1.SINGLE WALL D 2.DOUBLE WALL 90.NONE -r64-d VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT C3 1.STEEL 0 4.FIBERGLASS El 10.RIGID PLASTIC El 90.NONE 0 99.OTHER(Spec ify): 464cl. 4647- VENT SECONDARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS [3 10.RIGID PLASTIC El 90.NONE C3 99.OTHER(Specify): 464n. VR PRIMARY CONTAINMENT E3 1.STEEL 1@ 4.FIBERGLASS E3 10.RIGID PLASTIC [3 90.NONE E3 99.OTHER(Specifft 464& 464 1. 4& VR SECONDARY CONTAINMENT 0 1.STEEL N 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE E3 ".OTHER(Specify): 464111. 464 VENT PIPING TRANSITION SUMP TYPE 0 1.SINGLE WALL [1 2.DOUBLE WALL 0 90NONE RISER PRUVIARY CONTAINMENT E3 1.STEEL 0 4.FIBERGLASS D 10.RIGID PLASTIC (3 90.NONE [1 99.OTHER(Specify): 464. 4NI. 0 2 14 mem tv,law I Big a I N-3 fj 9-00-0�k;l 0 my 111 w I.I IMA --VH. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE IN 1.SINGLE WALL 2.DOUBLE WALL 469s, 3.NO DISPENSERS 0 90.NONE 469b. CONSTRUCTION MATERIAL 0 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 99.OTHER(specify) C. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION [1 2.SACRIFICIAL ANODE(S) 0 4.IMPRESSED CURRENT ■ FS6LXTION 449. 1X. APPLICANT SIGNATURE m-milln"171 I L' r f y L t 1 I- al is R 1,01, APPLICANT SIGNATURE DATE 09/18/2008 470. 47). APPLICANT NAME(print) JEFF LARSEN