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Jun 18 08 06:53p Allen Thomas 530-622-2275 p.11 <br /> 1 `F LSZ..� `C7 � 'l2. �'�l(� G(' 1�'�"�-': �� I '�lr'S��d'..(11-d-�ZO-•u <br /> UNERED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PER11II'T APPLICATION-TANK INFORMATION(Gae fa m LIST/ <br /> TYPE OF ACTION (Check one item onty. For m UST petmsoeat elosne ur[cmvB.camptctconty this upioD and Seuiaas p IV and IX below) na <br /> ❑ I.NEWPERMIT ❑ 3.RENEWAL PERG4'C S.CHANGEOFiNFORMATION�}���.y[.�JDi� <br /> Q 6.TEMPORARY UST CLOSURE 7.UST PERMANENTCLOSUREONSITE S.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: '� DATE Em-TING usTDLS(.'OVERED: aXoe <br /> L FACMM INPORMAT(ON <br /> FACILITY ID N(Agency Ure Only) - i <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-DoigBosim,Ax) 3 <br /> O�a Li �L tom, L <br /> BuslNEss SITE ADDRESS /�(A )ec <br /> U.TANKDESCREM4ON_ <br /> TANK IDN v2 TANK MANUFACTURER av TA mc ONTGURAmoN:TIRSTANx1S 4M <br /> ❑I.A STAND-AIANETANK <br /> �}C(S(,,,1?(S . oNE1NAcoMPAxTMENImUNtT. <br /> DATE USC SYSTEM BHSTALLID v5 arn�b ie 1de� <br /> TANK CAPACITY AF GALLONS 4T6 NUMBER OF COt�ARTMENIS IDI1'HE UNCI an <br /> 11L TANK IISB.AND.CONTENTS <br /> TANK USE I:MOTOR VEHICLE FUELING Q 1b.MARINA FUELING ❑ Ic AViATIONFUELQM 4D <br /> LJ 7.CHEMICAL,PRODUCTSTORAGE Q L HAZARDOUS WASTE Ibt Thmonl Q5-EMEROENCYGOERAMRFUELUMCtr5281J(Ol <br /> Q 6.OTHER GENERATORFUEL Q 95.UNKNOWN ❑99.OTHER ): 4X9. <br /> CONTENTS PETROLEUM: Q L.REGULARUNLEADED O Ic MKTGRADE IRKEADED T�.Ih PBEM1UM UNLEApED a <br /> Q 3.DSII, E3 5.lET FUEL j]6.AVIATION G1tS <br /> Q 8.PETROLEUM BLEND FUEL Q 9.OTTPRR PETROLEUM sl0a <br /> NOWPETROLEUM:Q 7.USED OIL Q 10.ETHANOL <br /> ILOTHFRNON-PETROLEUMS T/to <br /> . .IV--.TANK::CONSIRUCIIONTYPE OF 1_SINOLEWALL 2DOUBLEWALL 95-UNKNOwri 413 <br /> PREWAR.CONT'AOLMIIIT ❑ I.STEEL 3.FIBERGLASS 6,RITERNALBLADDER RR! <br /> Q <br /> z-- <br /> SECONDARY <br /> INLSRNAT,LKiIN(' ❑ 95.UNKO40WN 99.OTf¢-R 4Ha <br /> SECONDARY CONTAINMENT Q '4TEE. .FIBERGLASS Q 6.E7(TFRIOR61FldNRAN'EI3tJER Q7.JACKEfED 4as <br /> ❑ 95.UNKNOWN C399-OTHER ys <br /> OVERFILL PREVENTION 1.AUDIBLE&VISUAL,ALARMS 2BALLFTpAT 3.FII.LTUBESBUF-OFFVALVE lSZ <br /> ❑I.TANKMFETSREQUMSWE MFOREXEMPTIONPROMOVERFELPREVENTONEQT@N6f3fT <br /> V. PRODUCT`./:WASTE PWWGCONSTRUCTTON <br /> PIPING CONSTRUCTION ❑LSINGLE-WALLID DDURL&wATSED 99.ulI yp. <br /> SYSTEM TYPE 1-PRF-SSCXRE Q GRAVTY 0 <br /> 3,CONVENITONALSUCTON 1-SAFES[JCIIOl[ R�R42BN Ug <br /> PRNTARY CONTARA¢NL 1,S7TiEl, !.ETEIKLGCASS 8.tt cvro�F W.RJUM PLASTIC r6R <br /> Q 90.NONE ❑ 95.UNKNOWN ❑ 99- �y <br /> SECONDARY CONRAE9MQfT Q LSTEEI. 4,FIgpRG1Ass RFlF�IDIE 10-RIGID PLASTIC 46W <br /> Q 90.NONE 95_UNKNOWN ❑ 99.OTRER(SPcd&L- <br /> RFRc <br /> MINGATIRHINECOMAOK.GNTStIMP TYPE Q I.SRIGLE WAIL '-DOUBLE WALL MNONE <br /> . . VL VENT,VAPORRECOVERY( 'R);ANDRLSER1F9JlPJPEPII'ING�ONgFgQGTION:. _ . <br /> VIITT PRp1ARY CONTAINMENT' I.SLEFL 4.FIBERfBASS IQ IRIGB)PLASTTC 90.NONE 99-OTHEL(51aeiTi9 aNc <br /> VENT SECONDARYCONTAINMENT 1, 161et <br /> STEEL flA FIBERGLASS IQ RIGID PLASTIC wNONE 99.OTHEIl( ,.&) 46J[ <br /> VR PRXMARY CONTARiMENT I.SLEF7. 4. [ <br /> FIBERGTA,SS ITL RIGID PWST'IC 9a.NONE 99.OT@R(SI�TY) �s <br /> VRSECONDARYCONPAIl4b t LJ LSTEFI. -FiBERGTASS 0 ILRIDID PLASTIC 90.NOt� 99-0[HL7R(Sprtilyl IMh <br /> VIM PIPING TRANSMON SUMP TYPE (.SINGLE WAIL 46RhI <br /> Z.DOUBLE WAIL 9Q N01� 46a. <br /> BSER PRAIARY COMAKA@TT LSTEEL 1,FIBERGLASS IO.RIGID PLASTIC 9QNONE 99.OTBE$(Spaafy) 161j <br /> RISFRSECONDARYCONTAINMFNI' LSTEg7. 4.F®ERGLASS 20.RIGID PLASTIC 9Q NONE 99.OTHER(Spw*) J6R <br /> FILL COMPONEN75LNSfALLED 16RY1 <br /> BTICKET 3.STRIXFR PLATFJE171TDM PFWTECTTIR 1.CON/TAINMEN'f SIAAP 61ac <br /> V&UNDER DISPENSER CONTAMMENT.(UDC):. _ <br /> CON STRUCf10N TYPE [.SINGLE WALL ❑ ?,DOUBLE WARE. ❑3.NO DISPENSERS 13 90 NONE I(9s <br /> CONSTRUCTION MATERIAL .STEEL 4.F®EAGLASS ❑ W.RIGID PLASTIC [3 W,OTHER LS ,i5yy� <br /> VIII_. CORROSION:PROTEMON., <br /> STEEL COMPONENT PROTECTION Q 2SAIMPICIALANODEM Q 4,IMPRESSED CURRENT Q r.ISOLATIONN4 <br /> IX. APPLICANT SIGNATURE .. <br /> CERTIFICATION: I I- Nat Nis UST syslrao 6 compadhle with the ha>andoas aab5baea SRorad <br /> andd i• Mad tlut the haformaWa PRD91dtd herein Is ungn,Accarah, <br /> fallen itrem MN alremend, <br /> APPLICANT SIGNATUREDATE / <br /> APPLICANT NAME(print) aTi APPLICANTTTh-LE 4P- <br /> 6 <br /> ar �2tx - <br /> UPCF UST-B-T2 <br /> Re.,(1320071 <br />