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UNIFIED PROGRAM CONSOLIDA'T'ED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) - TYPE OF AGHON (Check one hear only. For a UST closure or removal,complete only(Iris section and Sectiones 1,11,111,IV,and lX belou) 430. NEW PERMIT ❑ 3.RENT_WAL PERMIT ❑ S.CHANGE•OF INFORMATION ❑ 6.'I'EMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL_ DA 1 E UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 430h. FACILITY INFOXZMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Scone as Docility Name o•DIIA--Doing Business As) f 3. 16l , I BUSINESS SIT i DD S s Io3• CITY r 104. II;::TANK DESCRIPTION TANK Ill# 432. TANK MANUFACTURER 433. TA K CONFIGURATION:THIS TANK IS 434- IR =D-ALONE TANK Compieie om page for exh 0 ❑2.ONE 1N A COMPARTMENTED UNIT C0.101m011 in the uaiL Alli USTSYTITM INSTALLED 435. TANK CAPACI�N GALLONS 436- NUMBER OP RTMENTS iNTIIE UNIT 437. �V `. III:-TA,Ni�USE;Ah1D CQNTEIVTS <.: / TANK USE MOTOR VEHICLE FUELING Q Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439• Q 3-CHEMICAI.PRODUCT STORAGE ❑4.HAZARDOUS WASTE(Includes Used Oil) ❑5.EMERGENCY GENERATOR FUEL IHS(t25281.5(c)) __ ❑6.OTHr:RGENERA"fORFUEL Q 95_UNKNO_W_N_ _ ___ _Q 99-OTHER(_Specify): 439x, CONTENTS_PETROLEUM: REGULAR UNLEADED Ic.MIDGRAD[UNLEADED - Q Ib.PREMIUM UNLEADED 440. ❑3.DIESEL ❑ S.JET FUEL ❑6.AVIATION GAS ❑8.PETROLEUM BLEND FUEL ❑9.O'lliER.PETROLEUM(�eciry): 440a _. - -- -- ------ - -------___..-- ._._._._. .. _._..-...._. - NON-PTsTROLEUM:❑7.USED OIL ❑ 10.ETHANOL ❑ 11.OT13ER NON-PETROLr:UM(S ecify): 440b. TY .T.�NK:CONSTRUCTIQN . TYPE OF TANKIli(It WALL ❑2.DOUBLE WALL ❑95.UNKNOWN 443• PRIMARY CONTAINMENT reJ.STEEL ❑3.FIBERGLASS [16.RTFERNAL BLADDER 444• ❑7.STEEL+INTERNAL LINING ❑95.UNKNOWN ❑99.OTHER(Specify): 444a SCONDCONTAINMENT ❑ t. EEL LX1'ERIOR MEMBRANE LINER Q 7.1ACKETEDEY 445. _4�0.NONE ❑95.UNKNOWN ❑99-OTHER(Specify): 445x. OVERFILL PREVPNTION ❑ 1_AUDIBLE&VISUAL ALARMS ❑2.BALL FLOAT ❑ 3-PILL TUBE SHUT-OFF VALVE 452 [14.TANK MEETS RE UIREMENI S FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT ::. .•.... :. ....-.: ... .::V.. PRODUCT/_WA;STE,EIPIN•G CONSTRiTCTION -, - :_- . .. .:: ... .; PIPING CONS"CRUC'fION SINGLE WALT, ❑2.DOUBLE WALL ❑99.OTIfFR 460. -... _-------- --_ __-. ._-...--------........- -- - --...- .......... ------ - - - - - -. SYSTEM TYPE- _ ❑ 1-PRESSURE- (12.GRAVITY $:J.CONVENTIONAL SUCTION [14_SAFE SUCTION 123 CCR¢2636(x)(3)) --45s_ PRIMARY CONTAINMENT ,_'rl.STEEL ❑4.FIBERGLASS ❑ 8.F1.Fxizu ❑ 10.RIGID PLASTIC 464• ❑90.NONE -- �]95.UNKNOWN ❑ 99.OTHER( ccify): -464a` SECONDARY CONTAINMENT ❑ 1.STEEL. ❑4.FIBERGLASS ❑S.FLEXIBLE Q 10.RIGID PLASTIC 464b. 0.NONE• ❑95.UNKNOWN ❑99.OTHER 464c. PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL, ❑2.DOUBLE WALL c$%NONE 1694 _•, VL..'V`I*;NT'V.�PQR.RECO,VELtY.{V,it)A,ND RISI+;It,/:FILL PIPE PIPINGCONSTRt�:CTION 464c. VENT PRIMARY CONTAINMENT 1 [3STEEL 4.FIBERGLASS [110.RIGID PLASTIC NONE [I99.OIIiER(Specify): 46101 464E VENTSECONDARY CONTAINMENT ❑ I.STEEL ❑4.FIBERGLASS Cl f0_RIGID PLASTIC r{7]Q0,NONE CI99.OTHER(Specify): 4640. VR PRIMARY CONTAINMENT ❑ 1.S"CEEt. [34-FIBERGLASS [3 10.RIGID PLASTIC 4®"ft NONE ❑99 OTHER(Specify): 4464_9_ VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC o.NONE ❑ 99.OTHER(Specify): 4464 -, -----------._.....__......--- ._... _... ------- ----- --- -- - . ...._.. 469(-.. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL I"10,NONE• RISER PRIMARY CONTAINMENT ❑ I.STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC NONE ❑ 99.OTIIER(Specify): 46aj. _ 464p-_ RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC 0.NONE ❑99.OTHER S eeif : 464A' �fL. (P Y) 464t1. FILL COMPONENTS INSTALLED ❑ L SPILL BUCKET ❑3.STRIKER PI.ATOBOTI'OM PROTECTOR ❑4.CONTAINMENT SUMP 451a4:. VII•. :UNDIRDTSPENSERCQNTAINMENT °.•.DC), (U CONSTRUCI'[ON TYPE _ ._ --0-!.S)NGLE\VACS:____..--•_--__-.-0 2_DOUBLE HALL. 3_NO DISPENSERS _NONE 469a CONSTRUCTION MATERIAL ❑ 1-STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4G9b. ': VIII: CQRR45IQN PItOTECT,ION. ; STEEL COMPONENT PROTECI'ION Q 2-SACRIFICIAL ANODr(S) ❑4.1MPRE•SSED CURRENT ❑6.ISOLA•I'(ON AtVL 448. IX. APPX,ICAIyT'SIGNATURE - CERTIFICATION:I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate,and in full compliance with le al requirements. APPLICANTSIGNATURE c DATE s 470. APPLICANT NAME(print)t- / 4 APPLICANT TITLE atz UPCF UST-0 Rev.(1212007)-1/2 3vww.unidoes.org b