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Alk <br /> ITN11FiED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(Onc form per LIM <br /> TYPE OF ACTION (Check one i(em only, t'or an UST perruanew clon.Ure or removal,complete only this sectiop and Sections 1,IL III,IV,and IX below) 430 <br /> Q 1,NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5,CHANGE OF INFORMATION <br /> ❑ &TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 8l UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED, 42W DATE EXISTING UST DISCOVERED: 4301 <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Onljq 7 <br /> BUSINESS NAME(Same Its FACILITY NAME or DBA-Doing Business As) Q 3 <br /> susINESS SIT ADUfttsS <br /> M TANK DESCRIPTION 7 <br /> TANK ID# '�} +32 TANK.k4ANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 <br /> 'TA ��' 5 � i �(�l t r(6) �01�(Y�N/{fC/��xl.A STAND-ALONE TANK <br /> �5 <br /> ❑2.ONE IN A COWARTMRNTF.n 1 Nrr. <br /> c6mplate one Wc for mch wtuonrtaml in She uLL <br /> DATE UST SYSTIAA EUQ ��t 435TANK CAPACITY IN GALLONS 436 NUMBER OF COM ARTMENT$IN THE UNIT 437 <br /> 7�` <br /> „c � r a <br /> III.TANK USE AND CONTENTS <br /> TANK USE la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIAT'lON FUELING 439 <br /> 3.CHEMICAL PRODUCT STORAGE ❑ 4,HAZARDOUS WASTE(ln fades Used OIp ❑ �.EMERGENCY GENERATOR FUEL(HSC§25281.5(c)] <br /> ❑ 6.OTHER6I1-NERATnR.FUEL ❑ 9i UNKNOAN ❑ 519.01HER (Specify);p0 fy); 434n <br /> CONTENTS PETROLEUM la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED Q ,16.PREMIUM UNLEADED 440 <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ �.AVIATION GAS <br /> ❑ d.PETROLEUM BLEND FUEL I OTHER PETROLFI r.V (S a' ) 44" <br /> NON-PETROL UM:Lj 7.USED OIL ❑ 1 <br /> 0.ETHANOL <br /> 11.OTI-(ER NON-PETROLEUM(Specify); 440b <br /> IV. TANK CONSTRUCTION <br /> TYPE OFT h ❑ I.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 <br /> PRIMARY CONTAINMENT ❑ I.STEEL 3,FIBERGLASS ❑ b.INTERNAL BLADDER as <br /> ❑ 7.STEEL INTER`AL LINING Q 95,UN1, OWN 99.0 i)ffR (Slotcifv): awn <br /> SFCC)--RY CONTAINMENT ❑ 1.STEEL FIBEKL LASS 6.E3CTERIOR MEMBRANE LRNER ❑ 7.JACKETED 445 <br /> Q 90,NONE �❑ 95.UNKNOWN ❑99.OTHER(S CiF;, 445. <br /> OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2,BALL FIAAT -01-73751LE TUBE SHUT-0FF VALVE 452. <br /> 4,TANK MEETS REQUIREMENT-S FOR EXEMPTION FROM OV.CRFILL PRLVLNTION EQUIPN[ENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑1.SINGLE-WALLED2.DOUBLE-WALLED 99.OTHER 1 460 <br /> SYSTEM TYPE 1 PRFCSl!RE .GRAVITY ❑ 3.CONVENTIONAL SUCTION 4.SAFE SUCTI N(23CCR¢2636(.x3)1 4$8 <br /> PRIMARY CON'[AINMENT I,STEEL _ 4.FIBERGLASS 8.FLEXIBLE 10_RIGID PLASTIC 467 <br /> ❑ 90.NONE 95.UNKNOWN ❑ 99,OTHER($ ify): 4544 <br /> SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 8,FLEXIBLE 1 ❑ 10.RIGID PLASTIC 464b <br /> LJ 90.NONE N95.UNKNOWN ❑ 99.OTHER(Specify): ii, 464e <br /> PIPINCVTURBIN'E CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL <br /> ❑ 90.NONE 4644 <br /> VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PE"G CONSTRUCTION <br /> VENT P ONTAINMENT 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLAS77C ❑ 9A.NONE 99.OTHER(Specify) 464c <br /> VENT SECONbARY CON TA1\N4 N7 ❑ 1.S1'EGL ❑ o,FIBERGLASS Q l0.RIGID PLASTIC L7F.NONE 46407 <br /> P ❑ 99.01 tIER(Specay) 464f <br /> VP.PRIMARY CONTAINMENT ya.1 f1 <br /> 1.S I't:EL U 4. I ERGLASS ❑ 10.RIGID PLASTIC 9?.NONE 99.OTHER(Specify) 46gK <br /> VR SECONDARY CONTAINMENT ❑ 1,$[EEL 4.FIBERGLASS 10.RIGID pL4STIC 90_NONE 641 <br /> ❑ 99.OTHER(Specify) 464h <br /> VEN PIPING TRANC[TTnN Si IMP TIP£ 1.SI!GLL wntL anen7 <br /> RISER PRIMARY CONTAINWI NT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC NONE 4641 <br /> ❑ 9Q.NONE 99.OTHER(Specify) 464J <br /> RISER SECONDARY CONTAINMENT464'1 <br /> ❑ I,STEEL Lj 4.FIBERGLASS ❑ I0.RIGIp PLASTIC ❑ 90,NONE ❑ 99.OTHER(Sue.ll'y) 4na4 <br /> FI OMPONF.NTS INSTALLED I 1 0 1.SPILL BUCKET LI 3_STRIKER PLATF/BOTTOM PROTECTOR 4,CONTAMMENT SUMP 4(4ki <br /> VIL UNDER DISPENSER CONTAINMENT(I.IDIC) <br /> CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2,DOUBLE WALL � 3.,N0 DISPENSER$ 90.NONE 469. <br /> CONSTRUCTION MATERIAL 0 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 9q,OTHER(Specify) 464b, <br /> VIII. CORROSION PROTECTION <br /> STEEL CO1NPONF.t4T PROTECTION ❑ 2.SAGR[F7CIAL ANODE(S) ❑ 4,IMPRESSED CURRENT ❑ 6.ISOLATION 448. <br /> Ix.,ANNLICAIN.T SIGNATURE. <br /> CERTIFICATION: I certify that this UST system is compatible with the ha-srdous subctanee sta <br /> and in fom Hance with 1 ruirements red rand the the Iururmauo7a provided herein Is true,tteettrate, <br /> VIC <br /> APPLICANT SIGNATURE DATE �Q� t 470. <br /> APPLICANT NAME(print) 471 APPLICANT TITLE j1 47z. <br /> UMV UST.R.1/2 i <br /> 60/60 30Vd GOOA SV9 3NO V 9L9LEE860Z i0 :Z0 6013�W0i <br />