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10/03/2007 09:40 AL #0050 P.009 /021 0i LL � _ tk!i . UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(0119 form m UST) TYPE OF ACTION (Check one item only. For an UST pamammt closure or removal,complete only this secdon and Sections 1,ll,III,IV,and IX below) 430 ❑ 1.NEW PERMIT ❑ 3.RENEWAL.PF?RM1T 5.CHANGE OF INFORMATION fl.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE .LIST REMOVAL DATE INT PERMANENTLY CLOSED; 4 ' DATE E1CISTING UST DISCOVERED: 430b L FACILITY'INFORMATION FACN-"ID#(.Agency Use Only) - I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) i-W-�� C1T&l J13 6LL, 3 BUSINESS S17'E ADDRESS (eq;-7 q , 03 CITY Y 104 II:TANK DESCRIPTION TAMC 1D 4;:! TANK MAN[TFACTURFt 433 TANK CONFIGURATION!THIS FANK LS 1134 O/� El1.A STA ND-ALONETANK v � f T uS Lo ❑2.ONE IN A faOKPAR7 NreD UNIT in the t DATE UST SYS INSTALLED 1133 TANK CAPACITY IN GALLONS 436 NUMBEROne OF CO ARTMENTS IN TI'IE:UNIT 437 III:TANK USE ANDCONTENTS. TANK USE t2-.MOTOR Van=FUELING ❑ Ib.MARINA FUELING ❑ 1c.AVIATION FUELING 439 3-CHEMICAL PRODUCT STORAGE 13l 4.HAZARDOUS WASTE(kxuw Uscd oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§2 uu8 e)) Q 6.OrHERGRNERAL El FUE95.UNKNOWN ❑99.OTHEP (S ): 439a CONTENT$ PETROLEUM: I&REGULAR UNLEADED Q lc.MIDGRADF.UNLEADED ❑ 1 b.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ S.JET FUEL [16.AVIATION GAS Q 8.PETROLEUM DLEND FUEI, ❑ 9.OTHER PL-IROLEUM (specify): 440a NON-PE rROLETJM;❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OT-M NON-PETROLEUM 5 440b IV- TANK CONSTRUCTION TYPE OF TANK Q I.SINGLE WALL 2.DOUBLE WALL ❑95.UNKNOWN 443 PRIMARY CONTAINMENT I.STfin ❑ 3.FIBERGLASS ❑6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LiNM [195.UNKNOWN ❑99.OTHER S "(y): 4"11 SECONDARY CONTIA OAENT ❑ 1.STEEL 3.FIBERGLASS [16-EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION 11 1.AUDIBLE tit VISUAL ALARMS 2.BALI,FLOAT Q 3.FILL TUBE SHUT-OFF VALVE 452, ❑ 4.TANK MUM REQUIREMENTS FOR oovW ION FROM OVERFILL PREVENTION EQUIPMENT V:,PRODUCT f.WASTE PIY'ING CONSTRUCnON PIPING CONSTRUCTION 111.SINGLE-WALLED ®,2.DOUBLE-WALLED99.OTHER 460 SYSTEM TYPE 1.PRESSURE El 2.GRAVITY ❑ 3.CA,tVENTIONAL SUCTION Q 4.SAFE SiiCTION 123 CCR 2636(4(3)1 43$ PRIMARY CONTAINMENT !.STEEL M 4.FIBERGLASS ❑ 8,FLEXIBLE ❑ 10.R(GID PLASTIC 464 ❑ 90.NONE ❑95.UNKNOWN ❑ 99.0TIIER(Spad y): 464a SECONDARY CONTAINMENT ❑ 1.STEEL 40 4.FIBERGLASS ❑a.FLUMBLE ❑ 10.RIGID PLASMIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.0THER(3pevfy)r 464c PIPINGITURBINF.CONTAINMENT SUMP TYPE ig L SINGLE WALL 13 1 DOUBLE WALL ❑ 90_NONE 4644 VI,VENT,VAPOReorvERY.(VR),A,ND RISER IF[;IrL PIPE PRgNG CONSTRUCTION VENT PRIMARY CONTAINMENT U I.STEEL 0(4.FIBERGLASS ❑ l o.RTGTD PLASTIC ❑ 9o.NOME 0 99.OTFTER(Spaelfy) 4(119 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL in 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE ❑ 99.pTRxR(SPcdfy) 464? 464f1 VR PRIMARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS p 10,RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Spedfy) 464s VR SECONDARY CONTA]NMENT491 ❑ I.STEEL �I 4,FIBERGLASS 10.RIGID PLASTIC 90.NONE ❑99.OrHER(Specify) 464h 444hi VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL2.DOUBLE WALL 90.NONE 4641. RISER PREUARY CONTAINMENT ❑ 1.STEEL ja 4.FIBERGLASS LJ 10.RIGID PLASTIC 0 90.NONE ❑ 99.0IIiER(Specify) 464j RISER SECONDARY CONTAINMENT 0 1.STLTT. Iq 4_FIBERGLASS ❑ 10.RIGID PLASTIC ❑90.NONE 99.OTHER(Specify) 464r 464ki FILL CO-WONUNTS INSTALLED B 1.SPILL$UCKET 3.STRHM PLATEMOTTOM PROTECTOR 11 4.CONTAINMENT SUMP 45lam SIL,U"ER DISPENSER COWAINNUENT JUDO CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑3.NO DfSPENSERS Q 90.NONE 46% CONSTRUCTION MATERIAL ® 1.STEEL ❑4.FIBERGLASS 10•RIGID PLASTIC ❑ ".OTHER.(Specify) 469b e VIIT:''COR'ItQSION'PROTECTION . STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODU(S) ❑4.IMPRESSED CURRENT ❑6.ISOLATION " 448. IX- APPLICANT'SIGNATURE' CERTIFICATION:I certifythis system coeapsUbM with the haurdous substance stored and that the hiformation provided hereto is Lr*jmnrate, Ind in C e with sI recmireumats. APPLICANT SIGNATURE DATE f? _,.: 470. APPLICANT NAME(print) 471. APPLICANT° 1711E 472 c� UP'CF UST-B-1/2 Rev.(12l2007)