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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (one form per usT`P ll TYPE OF ACTION (Check one item only. For an UST permanent closure or removal, complete only this section and Sections I, IL III, IV, and IX below) 430 NEW PERMIT ❑ 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 43031 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID # (Agency Use OWy) _ _ 7 0 G I B $INESS NAME (Same as FACILITY NAME or.DBA-Doing Business As) 3 BUSD, F,SS SITE ADDRESS 103 CITY 04 14 U. TANK DESCRIPTION TANK ID # T 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK 1S ❑ 1- A ND -ALONE TANK �� R[ /T`v1rZNiCi� 'kt� Q` " INACCOMPARTMENTED �ARTMEED �( i' �r DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARMAENTS IN THE UNIT '2 M. TANK USE.AND CONTENTS TANK USE ❑ la. MOTOR VEHICLE FUELING ❑ Ib. MARINA FUELING ❑ Ic. AVIATION FUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Iodude Used Oir) ❑ 5. EMERGENCY GENERATOR FUEL (Fisc ¢25m i-Xc)] ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ Ia. REGULAR UNLEADED ❑ 1r- MIDGRADE UNLEADED ❑ lb. PREMIUM UNLEADED 440 ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. P OLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM S 4403 NON -PETROLEUM: USED OIL ❑ 10. ETHANOL ❑ 11. OTHER NON-PETROLEUM(Specify): 440b . -TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL UF DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT STEEL ❑ 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (S ): 444a SECONDARY CONTAINMENT STEEL ❑ 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify) 445a OVERFILL PREVENTION ❑ 1. IBLE & VISUAL ALARMS 2. BALL FLOAT 3. FILL TUBE SHUT-OFF VALVE 452 TANK [MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT.! WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION SINGLE -WALLED ❑ 2. DOUBLE -WALLED ❑ 99. OTHER 460 SYSTEM TYPE OL,-. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION 23 CCR J2fiWaX3)j 458 PRIMARY CONTAINMENT ©.!!STEEL ❑ 4. FIBERGLASS ❑ S. FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC4646 ❑ 90. NONE [195. UNKNOWN 99. OTHER (Specify): I - J i- i ( 464c PIPINGITURBINE CONTAINMENT SUMP TYPE ❑ 1. SINGLE WALL ❑ 2. DOUBLE WALL 90. NONE 464d VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT EL 0 4. FIBERGLASS C1 10. RIGID PLASTIC 0 90. NONE 0 99. OTHER (Specify) 464e 464e1 VENT SECONDARY CONTAINMENT I. STEEL 0 4. FIBERGLASS 10. RIGID PLASTIC C3 90. NONE 99. OTHER (Specify) 464E 464f1 VR PRIMARY CONTAINMENT ❑ 1. STEEL 0 4. FIBERGLASS C3 10. RIGID PLASTIC 90. NONE 99. OTHER (Specify) 4648 464 1 VR SECONDARY CONTAINMENT ❑ L STEEL C FIBERGLASS 10. RIGID PLASTIC 0 90. NONE U 99. OTHER (Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE Q 1, SINGLE WALL 0 ? DOUBLE WALL 90. NONE 464L RISER PRIMARY CONTAINMENT ❑ L STEEL 4. FIBERGLASS Lj 10. RIGID PLASTIC 0 90. NONE 0 99. OTHER (Specify) 464j 464' I RISER SECONDARY CONTAINMENT 0 L STEEL 4. FIBERGLASS 10. RIGID PLASTIC ❑ 90. NONE 99. OTHER (Spaity) 464k 464k1 FILL COMPONENTS INSTALLED 0 1. SPILL BUCKET 3. STRIKER PLATE/BOTTOM PROTECTOR 0 4. CONTAINMENT SUMP 451&-c VII. UNDER DISPENSER CONTAINMENT.(UDQ CONSTRUCTION TYPE ❑ 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS . ONE 469a CONSTRUCTION MATERIAL, ❑ 1. STEEL ❑ 4. FIHERGL.ASS ❑ 10. RIGID PLASTIC ❑ ".OTHER (S ) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4.1MPRESSED CURRENT )] 6. ISOLATION 448. IX. APPLICANT 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 f m fiance with legal requirements. APPLICANT SIGNATUREDATE azo. APPLICANT NAME (print) 471' APPLICANT TCTL an_ ��C� �• UPCF UST -B - 1/2 Rev. (12/2007) l3 43;1 3;1