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From. 11/03/2008 1517 #164 P 017/033 <br /> IFIED PROGRAM CONSOLIDATED FL <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) <br /> TYPE OF ACTION {Check one item only. Foran UST permanent closure or removal,complete only this section and Sections I,IT 111,IV,and IX below) 43D <br /> ,�r1.NEW PERMIT 0 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> 6.TEMPORARY UST CLOSURE C} 7.UST PERMANENT CLOSURE ON SITE 0 1 UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 431 1 DATE EXISTING UST DISCOVERED; <br /> NIA436b <br /> I. FACILITY INFORMATION Q" <br /> FACILITY <br /> FACILITY ID#(Agency Use Only) 3 1 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing usiness As) 3 <br /> FGA <br /> BUSINESS SITE ADDRESS 10 <br /> CITY <br /> 4 I- ! ��lo�, 90 r--.t r-mI � 104 <br /> II.TANK DESCRIPTION <br /> TANK ID 4' 43Z TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 <br /> \ <br /> RI A STAND-ALONE TANK <br /> madewin Weld d 111 2,ONE IN A COMPARTMENTED UNrr, <br /> Co Ine one a toc each oom mrnt ie the unit, <br /> DATE E UST SYSTEM INSTALLED 435 TANK CAPACITY C IN GALLONS 436 NUMBER 3 COMPARTMENTS iN THE UNIT 437 <br /> O p <br /> III. TANK USE AND CONTENTS <br /> TANK USE j9 la.MOTOR VEHICLE FUELING [] Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑4.HAZARDOUS WASTE(lacludes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC¢25281 5(c)) <br /> E36.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99-OTHER(Specify): 439a <br /> CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED [3 Ib.PREMIUM UNLEADED 440 <br /> 0 3.DIESEL 1:1 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (S cif): 440a <br /> NON-PETROLEUM:0 7.USED OIL ❑ 10.ETHANOL <br /> d it.OTHER NON-PETROLEUMS ecif): 440b <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ I.SINGLE WALL 2.DOUBLE WALL 95.UNKNOWN 443 <br /> PRIMARY CONTAINMENT J.STEEL ❑ 3.FIBERGLASS ❑6.INTERNAL BLADDER A44 <br /> ❑ 7.STEEL*INTERNAL 11MNG ❑95.UNKNOWN _Q_10.OTHER, (Specify): 444a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL IN 3.FIBERGLASS 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 <br /> ❑90.NONE ❑ 95.UNKNO WN ❑99.OTHER(Spec : 445a <br /> OVE ILL PREVENTION 1 AUDIBLE&VISUAL ALARMS n <br /> 2.BALL FLOAT W3 J.FILL TUBE SHUT-OFF VALVE 452 <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION 1.SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER 46b7-1 <br /> SYSTEM TYPE 19 ).PRESSURE ❑ 2.GRAVITY ❑3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR F2636(wx 458 <br /> PRIMARY CONTAINMENT ❑ T STEEL 19 4.FIBERGLASS 0 S.FLEXIBLE 10.RIGID PLASTIC 464 <br /> ❑ 90.NONE [195.UNKNOWN ❑ 99.OTHER(Specify): 464a <br /> SECONDARY CONTAINMENT © 1.STEEL N 4.FIBERGLASS ❑ 8.FLEXIBLE [} 10.RIGID PLASTIC 464b <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL 19 2.DOUBLE WALL 90.NONE 464d <br /> VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS 0 10,RIGIDPL.ASTIC ❑90.NONE 99.OTHER(Specify) 464e <br /> 464c1 <br /> VENT SECONDARY CONTAINMENT El I.STEEL 14 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE C3 99.OTHER(Specify) 4641' <br /> 464tr <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4648 <br /> JY JA 464SI <br /> VR SECONDARY CONTAINMENT 3.STEEL 0 4.FIBERGLASS ❑ 1 O.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464h <br /> M 1A 464h1 <br /> VENT PIPING TRANSITION SUMP TYPE L SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 4641 <br /> RISER PRIMARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC U 90.NONE 0 99.OTHER(Specify) 464j <br /> 464'1 <br /> RISER SECONDARY CONTAINMENT I.STEEL 19 4.FIBERGLASS El 10.RIGID PLASTIC E3 90.NONE ❑ 99.OTHER(Specify) 464k <br /> 464k1 <br /> FILL COMPONENTS INSTALLED 1.SPILL BUCKET 0 3.STRIKERPLATEBOTTOM PROTECTOR 4,CONTAINMENT SUMP 451a-c <br /> VII.UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ❑ 1.SINGLE WALL FS 2.DOUBLE"WALL ❑ 3.14-0-DISPENSERS ❑ 90.NONE 469a <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) a69b c <br /> VIII, CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑2.SACRIFICIAL ANODES) ❑4.IMPRESSED CURRENT 6.ISOLATION 448 <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein Is true,accurate, <br /> and in full com nce with le al requirements. <br /> APPLICANT SIGNATURE DATE 476 <br /> APPLICANT NAME(prim U 7�` 471 APPLICANT TITLE B 472 <br />