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t <br /> VV j <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK / <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (Chat a2l, <br /> TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sect/am 1,411(IF.and IX below) 4" <br /> ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT 5 5.CHANGE OF INFORMATION <br /> 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 439a DATE EXISTING UST DISCOVERED ^ <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) <br /> BUSINESS NAME(Same m Facility Name or DBA(�-Doing Bminess As) 3. <br /> BU INESSSTfEADDRESS Er�/) t CRYG/-yJ�'}.� l IN <br /> Sv 1 l ll y'ti L..),,.' ✓ �✓C 1✓vim <br /> H. ANK DESCRIPTION <br /> TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. <br /> / LA STAND-ALONE TANK Coapht pm test,krrrA <br /> I O I ---q U V �r� 2.ONE IN A COMPARTMENTED UNIT rupnam,b me- <br /> DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 4vu 1 NUMBER OF COMPARTMENTS IN THE UNIT 437. <br /> III. TANK USE AND CONTENTS <br /> TANK USE 0 in.MOTOR VEHICLE FUELING IM Its.MARINA FUELING ❑ le.AVIATION FUELING 439. <br /> 0J.CHEWCALPRODUCT STORAGE 04.HAZARDOUS WASTE(ba-Iha40R) 05.EMERGENCY GENERATOR FUEL(IBC125261J(c)1 <br /> 0 6.OTHER GENERATOR FUEL Cl 93.UNKNOWN _ 0 99.OTHER(Spec fy): 43% <br /> CONTENTS PETROLEUM: 0 in.REGULAR UNLEADED O to.MIDGRADE UNLEADED 0 Ib PREMIUMI1NLrADED 4f9 <br /> $J.DIESEL 0 5.IEr FUEL 0 6.AVIATION GAS <br /> 0 8.PETROLEUM BLEND FUEL _ E3 9.O IM PETROLEUM(Spnfy): 440- <br /> NON-PETROLEUM: 7.USED OIL ff 10.ETHANOL --_ <br /> 11.OTTER NON-PETROLEUMS i ) 4496. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK O LSINGLEWALL jjk2.DOUBLEWALL 9s.UNKNOWN 403. <br /> -._ - -. ---------- - ------- . <br /> PItBs1ARY CONTAINMENT M I.STEEL � J.FIBERGLASS E3 <br /> 6.INNAL BLADDER 444 <br /> 13 7.STEEL+INTERNAL LINING95.11NKNOWN 099.0TTEt(Specify): <br /> SBCONDARY CONTAINMENT 0 L STEEL--0 3.FIBERGLASS 0 6.1iXTER10A MEMBRANIJIINBR O 7.TACK6TPD -_. 445. <br /> 0 90.NONE 0 95.UNKNOWNlg 99.oTTJER(Rt '�'Y I-;(x ,At•,S5 <vc1••.4 (4U- <br /> OVERFILL PREVENTION 0 1.AUDIBLE&VISUAL ALARMS 0 2.BALL FLOAT 3.FILL TUBE SHUT-0FF VALVE 452 <br /> 4.TANK MEETS REQUFIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION O 1.SINGER WAIL 2.DOUBLS WALL_ p 99.GOER _ _ <br /> SYSTEMTYPE 1.PRESSURE 0 2.GRAVDY [] 3.CONVENTIONAL SUCTION 0 4.SAFE SUCTION I23 CCR NW603)143L <br /> PRIMARY CONTAINMENT 0 1.STEEL A&4.FIBERGLASS 0 8.FLEXIBLE 0 10.RIGID PLASTIC 4N. <br /> Q 90.NONE [195.UNKNOWN 0 99.01THER( k 46N <br /> SECONDARY CONTAINhffiNT 0 1.STEEL -m 4.FIBERGLASS 0 8.FLEXIBLE E 0 10.RIGID PLASTIC 444E <br /> _ 0 90.NONE 0 95.UNKNOWN 0 99.o1Impp aly_$ 4e4e <br /> PIPINGRURBINE CONTAINMENT SUMP TYPE at.SINGLE WALL 13 2.DOUBLE WALL 90.NONE 464a <br /> VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT a 1.STEEL 0 4.FIBERGLASS 0'10 RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify): 4661 <br /> VENT SECONDARY CONTAINMENT 0 1.STM 0 4.FIBERGLASS 0.10.RIGID PLASM $90.NONE 0 99.07MM(Spleffi : a6 u <br /> VR PRIMARY CONTAINMENT _.._ 0 L STEEL 0 4.FIBERGLASS 0 10.RIGID PLASM a 90 NONE 0 99.O HER(Specify): 40 <br /> VR SECONDARY CONTAINMENT - 0 1.STEEL [14.FIBERGLASS O IQ RIGID KASRC a 90.NONE El".o m(Specify): 464ht <br /> __- <br /> VENT PIPING TRANSITION SUMP TYPE _0 L SINGLE WALL O 2.DOUBLE IVALL R90_NONE <br /> RISER PRIMARY CONTAINMENT 10 1.STEEL ❑ 4.FIBERGLASS 0 IQ RIGID PLASTIC O 90.NONE 0 99.OTHER(Specify): <br /> RISER SECONDARY CONTAINMENT 01.STEEL 04.FIBERGLASS 010.RIGID PLASTIC Q 90.NONE 099.OTHER(Speclfy): 46at1 <br /> PILL COMPONENTS INSTALLED JR 1.SPILL BUCKET EF 3.STRIKER PIATPJBOTfOM PROTECTOR 0 4.CONTAINMENT SUMP lac <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ;R I.SINGLE WALL [3 2.DOUBLE WAIL 3.NO DISPENSERS 90.NONE <br /> -. - -NE - <br /> CONSTRUCTION MATERIAL I.STEEL ❑ 4._FIBERGLASS [3I0.RIGID PLASTIC [3-99.OTHER(Sp __ecify) <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION 2.SACRIFICIAL ANODE(S)C3 4.IMPRESSED CURRENT 6.ISOLATION 446 <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: 1 certify !a.* <br /> hat i T t is compatible with the hazardous substance stored and that the information provided hello is true, <br /> accurate an (n 11 c a ee with]!Set requirements. <br /> APPLICANT SIGNATURE DATE 416. <br /> 17 /Z <br /> APPLICANT NAME(print) ,5 6 _ 411 APPLICANT TITLE M"24 p M ANr � 4` <br /> iu ^ <br /> UPCFUST.BRev.(I22007) 112 www.unidocs.org <br />