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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (one form 11 y's per UST) 11 it L� 6 aw wuyncic vuiy ums Section aria aecuon5 1, 11, 111, IV, and IX below)bdZ NEW PERMIT ❑ 3. RENEWAL PERMIT C15. CHANGE OF INFORMATION 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: a3oa DATE EXISTING UST DISCOVERED: 430b I. FACILM INFORMATION FACILITY ID # (Agency Use Only) _11 _ 1 le 1 B INESS NAME (Sarre as FACILITY NAME or DBA -Doing Business As) 3 BUSINESS SrF)E ADDRESS l03 CITY C II. TANK DESCRIPTION TANK ID #r�� aC .^I? llOO TANK MANUFAC)ER jV L )�', .�/'� , `--1 ` r\ d f a3avIa3z ❑ I.,4 -STAND-ALONE TANK .ONE INA COMPARTMENTED UNIT. CoffnActeon page for each camputment mthe wit c -r DATE UST SYSTE INSTALLED 435 Z TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS -EN THE UNIT 437 III. TANK USE AND_CO_NTENTS TANK USE ❑ la. MOTOR VEHICLE FUELING ❑ Ib. MARINA FUELING ❑ lc. AVIATION FUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Indvdm Used Oil) ❑ 5. EMERGENCY GENERATOR FUEL [HSC §25281-Xc)] ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN 0,K. -OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la. REGULAR UNLEADED ❑ Ic. MIDGRADE UNLEADED ❑ Ib. PREMIUM UNLEADED 440 ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8.P LEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (specify): 440a NON -PETROLEUM: D OI. ❑ 10. ETHANOL 1. OTHER NON-PETROLEUM(Specify): t:% 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.51NGLEWALL 97DOUBLEWALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT . STEEL ❑ 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 ❑ 7. STEEL+ INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (specify): 444a SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445 ❑ 90. NONE ❑ 95. UNKNOWN 0 99. OTHER (Specify): 1 1 , s :Ie 445a OVERFILL PREVENTION 1. AUDIBLE & VISUAL ALARMS 2. BALL FLOAT [13. FILL TUBE SHUT-OFF VALVE 452. 61 ria. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT / WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 1. SINGLE -WALLED [12. DOUBLE -WALLED ❑ 99. OTHER 460 SYSTEM TYPE C". PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR ¢2636(ax3)] 458 PRIMARY CONTAINMENT . STEEL ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 46a ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE 0 10. RIGID PLASTIC 464b ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464c PIPINGITURBINE CONTAINMENT SUMP TYPE ❑ 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE 4644 VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 91. STEEL 0 4. FIBERGLASS 10. RIG[D PLASTIC 0 90. NONE ❑ 99. OTHER (Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4. FIBERGLASS 10. RIGID PLASTIC ❑ 90. NONE 0 99. OTHER (Specify) 464f 464f1 VR PRIMARY CONTAINMENT C1 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE 99. OTHER (Specify) 464g 464 1 VR SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE ❑ 1. SINGLE WALL C1 2. DOUBLE WALL 90. NONE 4640 RISER PRIMARY CONTAINMENT ❑ 1. STEEL 0 4. FIBERGLASS ❑ 10. RIGID PLASTIC C1 90. NONE ❑ 99. OTHER (Specify) 464j 464' 1 RISER SECONDARY CONTAINMENT C1 1. STEEL 0 4. FIBERGLASS 0 10. RIGID PLASTIC ❑ 90. NONE 99. OTHER (Specify) 464k 464k1 FILL COMPONENTS INSTALLED ❑ 1. SPILL BUCKET ❑ 3. STRIKER PLATEBOT 0M PROTECTOR ❑ 4. CONTAINMENT SUMP 45la-c VII. UNDER DISPENSER CONTAINMENT (UDC). CONSTRUCTION TYPE ❑ L SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS Q.9Q: NONE 469. CONSTRUCTION MATERIAL ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 469be VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED 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 full compliance with legal requirements. APPLICANT SIGNATURE DATE 4M APPLICANT NAME (print) n _ 471 APPLICANT TITLE 4n- UPCF UST -B - 1/2 Rev. (12/200')