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10/03/2007 09:39 #0050 P.007 /021_ UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION--TANK INFORMATION(onc form per UST) TYPE OF ACTION (Check one item only. Foran UST peml out closure or removal,oomplate only this section and Sections I,If,III,IV,and IX below) 430 ❑ L NEW PERMIT 1K 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ T UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL. DATE UST PERMANENTLY CLOSED: 43W DATE.EXISTING UST DISCOVERED: 430b L FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as FACILITY NAMF, g SA-Dpi S' As} 3 IQ 1 BUSINESS SITE ADDRES& j ' C 104 c IL TANK-DESCRIPTION. TANKnID# 113 432 TANK MANUFACTURER 433 TA14K CONFIGIIRA'nON:TATs TANK Is 434 LOINM A NK ONE INACOMPARATME TQDUNIT. DATE UST VWSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMB M- Of-COMPARTMENTS IN THE UNIT 437 III.TANK USE AND CONTENTS' TANK USE la.MOTOR VEHICLE FUELING © !b.MARINA FUELING El1C.AVIATION FUELING 434 3.CHEMICAL PRODUCT STORAGE ❑4.I1ALARDOUS WASTE(T dedm Uscd Oil) ❑ 5.EMERGENCY GENERATOR FUEI.IHW§Z5291.5(c)1 [] 6.OTTIER GENERATOR FUEL ❑95.UNKNOWN ❑ 99.OTHER(Swifr): 4392 CONTENTS PETROLEUM: ❑ Ia_REGULAR UNLEADED ❑ Ic.MIDGRADF UVLP,ADIID lb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑9.OTHER PETROLEUM (S ): 4401 NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 11.OTHER NON-PETROLEUM(S 440b IV:.TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 9 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRWAkY CONTAIN.;ENT 1.STUL [11.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING [2 95.UNKNOWN ❑ 99.OTHER (S 444a SECONDARY CONTAINMENT ❑ I.STEEL IN 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LIVER ❑ 7.JACKETED 445 ❑ 90.NONE ❑95.UNKNOWN ❑99.OTHER(Spec*):): 445a OVERFIU.PRRVE". ON ® 1.AUDIBLE&VISUAL ALARMS '[12.BALL FLOAT Q 3.FILL TUBE SHUT-AFF VALVP, 452 {�4.TANK MFP.TS RF.QUIRFMENTS FOR EXEMPTION FROM OVFRFi1.T.PRF VEVTTON EQUIPMF?IN7 V. PRODUCT/WASTE PIPINGCONs''TRIICTION. PIPING CONSTRUCTION ❑1.SINGLE-WALLED 19 2.DOUBLE-WALLED ❑99,OTHER 46U SYSTEM TYPE 1.PRESSURE ❑2.GRAVITY Q 3.COV VF1N-IIONAT.SUCTION ❑ 4.SAFE.SUCTION[23 CCR$26Wz)(3)I 458 PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS E38.FLEXIBLE ❑ 10.RIGID PLASTIC ❑90.NONE 95.UNKNOWN [399.OTEIMSpecify): 464a SECONDARY CONTAROAENT ❑ 1.STEEL 614.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑90.NONE ❑95.UNKNOWN ❑ 99.OTHER(Spec fy): 464c PIPING/TURBTNT_CONTAINMENT SUMP TYPE Cd 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECOVERY")AND RISER I FILL PIPE PIPING CONSI'RUC HON. VENT PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.N01N� 99.OTHER(Specify) 464e 464eE VENT SECONDARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑90.NONE ❑ 99.OTHER(Specify) 4611 4taft VR PRIMARY CONTAINMENT ❑ I.$TEFL Q 4.FIBERGLASS I0.RTGTD PtASTTC ❑90.NOXTI 0 ".OTHER(Spec;$) 4641- 1 VR SECONDARY CONTAINMENT ❑ 1-STEEL 4.FIBERGLASS E3 10.RIGIDPLASTIC 0%.NONE 99.OmER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYP1 1.STNGT F WALT ❑2.DOUBLE WALL 90•NONE 4541 RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC INNER Ej 99.OTHER(Specify) 464} 464'1 RISER SECONDARY CONTAINMENT p L STFEI, §j 4.FTgERGLASS 10.RIGID PLASTIC ❑90-NONE ❑ 99,OTHER(Spcc*l 4464 FILL COMPONENTS INSTALLED IRLSPILLBUCKET ❑ 3.STRTKP.R PLATTJBOTTOM PROTECTOR 4-CONTAINMENT SLrMP 4512- VYI.UNDER DISPENSER CONTAEVMENT([UDC) CONSTRUCTION TYPE '0-1,SINGLE WALL ❑2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE-, 4692 CONSTRUCTION MATERIAL 1.STEEL ❑4.FIBERGLASS ❑ W.RIGID PLASTIC ❑ 99.OTHER( ) 469bc VIII: CORROSION PROTECTION STEEL COMPONENT PR OH ❑ 2.SACRIFICIAL ANODE(S) ❑4.tMPPSMED CURRENT ❑6.ISOLATION 443, IX APPLICANT'SIGNATURE CERTIFICATION.I , fy is UST system Is compatible with the buardous substance stored aed that the information provided herein is t rut sccutst-_ in fug itpliame with Imal regidrements. APPLICANT SIGNA F. DATE © ® 470. APPLICANT NAME(pr ) r 471. APPLICANT TITLE 47� UPCF UST-B-1/2 Rev-(I 212W