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From 11/03/2008 15 39 #164 P 019/033 <br /> IFIED PROGRAM CONSOLIDATED F� M� <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) <br /> TY?E OF ACTION (Check one item only. For an UST permanent closure or removal,Complete only this section and Sections I,11,111,IV,and IX below)mwanowwwo 430 <br /> 0 1 NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL, <br /> DATE UST PERMANENTLY CLOSED: NIA 4300 1 DATE EXISTING UST DISCOVERED: 4306 <br /> I. FACILITY INFORMATION71, 5a <br /> FACILITY[D#(Agency Use Only) ._.. �3 t <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 <br /> BUSINESS SITE ADDRESS5 Io3 CITY 104 <br /> II.TANK DESCRIPTION <br /> TANK ID ,Q �` 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 <br /> �/ I.A STAND-ALONE TANKj <br /> d V'R L z0 o Ie fu <br /> N 0each c TMENTED UNIT, <br /> l <br /> Ment ie the unit <br /> DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 415 NUMBER OF COMPARTMENTS IN THE UNIT 437 <br /> E3C=�99 <br /> III.TANK USE AND CONTENTS <br /> TANK USE JW Ia.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE tlndwa Und Oil) ❑ 5-EMERGENCY GENERATOR FUEL IHSiC§25281 5(c)) <br /> ❑ 6,OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a <br /> CONTENTS PETROLEUM: ❑ in.REGULAR UNLEADED ❑ It.MWGRADE UNLEADED ❑ 1b.PREMIUM UNLEADED 440 <br /> ❑ 3.DIESEL ❑ S.)ET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL V 9.OTHER PETROLEUM (S cif§): 440a <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.E'T'HANOL <br /> ❑ 11.OTHER NON-PETROLEUM(Specify); 440b <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL 19 2.DOUBLE WALL ❑ 95.UNKNOWN 443 <br /> PRIMARY CONTAINMENT I.STEEL U 3.FIBERGLASS ❑ &INTERNAL BLADDER 444 <br /> ❑ 1.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑99.OTHER (Specif): 444a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.E1(TERIORMEMBRANE LINER ❑ 7 JACKETED 445 <br /> ❑ 90.NONE 95.UNKNOWN ❑L OTHERS ci 445a <br /> OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT 3.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 [199.OTHER 460 <br /> SYSTEM TYPE 1.PRESSURE 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR§2636(QX3)j 456 <br /> PRIMARY CONTAINMENT ❑ t.STEEL 18 4.FIBERGLASS 0 8.FLEXIBLE ❑ I O.RIGID PLASTIC 464 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 464a <br /> SECONDARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER_(Specify): 464c <br /> PIPINGITURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL 252.11flUBLE WALL 90.NONE 464 <br /> VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE ❑99.OTHER(Specify) 464e <br /> 464e1 <br /> VENT SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ f0.RIGID PLASTIC 90,NONE 0 99.OTHER(Specify) 464f <br /> 464b <br /> VR PRIMARY CONTAINMENT 0 1.STEEL 191 FIBERGLASS 0 10,RIGID PLASTIC CT 90.NONE 0 99.OTHER(Specify) 4648 <br /> 46491 <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL J1 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h <br /> 464ht <br /> VENT PIPING TRANSITION SUAiP TYPE I.SINGLE WALL 2.DOUBLE WALL 90.NONE 464i <br /> RISER PRIMARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS ❑ I O.RIGID PLASTIC U 90.NONE 99.OTHER(Specify) 464j <br /> a641 <br /> RISER SECONDARY CONTAINMENT 0i.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 464k <br /> a6akt <br /> FILL COMPONENTS INSTALLED I.SPILL BUCKET 3.STRIKER PLATEfBOTTOM PROTECTOR 4.CONTAINMENT SUMP 451a< <br /> VII.UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTIONTYPE ❑ I SINGLE W_ ju 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑90.NONE 469a <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL W 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER($pecify) 4696-c <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES) ❑4.IMPRESSED CURRENT 6,ISOLATION 44s <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 compliance with legal re ements. <br /> APPLICANT SIGNATURE DATE -070 <br /> c <br /> APPLICANT NAME(print) ` d71 APPLICANT TITLE 472 <br /> Y� n c I �� �� <br />