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low g/ UNIFIED PICOGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TAMC " OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per Us n "TYPE OF ACTION (Check one item only. For ST closure or removal,complete only this section artd Sertio77s 1.11.111.IF,and 1�'betow) a30 [.NEW PERMIT 3,RENEWAL PERMIT 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSUREPERMANENT CLOSURE ON SITE S.UST REMOVAL DATE UST PERMANENTLY CLOSED: 431 DATE EXISTING UST DISCOVERED. 4 k0h I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUST ME(Same as Facility,Name or DBA-Doing Busine As) �r' esorT BUST SS SITE ADD R 1Q CITY II. TANK D SCRIPTION TANK ID# 43' TANK MANUFACTURER 1 TANK CONFIGURATION,THIS TANK IS 434. r1.A STAND-ALONE TANK Complete ase page for each 92.ONE IN A CQMPARTMENTED UNIT etnnpaunent in Inc unit. DATE UST§YSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 438. NUMBER OF COMPARTMENTS IN THE UN17F 437 a III. TANK USE AND CONTENTS TANK USE Q la.MOTOR VEHICLE FUELING Q-n.MARINA FUELING ❑ Ic.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Include used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC J25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑95.UNKNOWN ❑ 99.OTHER(specify): 439s. CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED 1c.MiDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS _ Q S.PETROLEUM BLEND FUEL C39.OTHER PETROLEUM(S ifs 440L NON.PETROLEUM: 7.USED OIL U 10.ETHANOL -W -- ❑ t..OTHER NON-PETROLEUMS i ): 440b, IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL DOUBLE WALL 95.UNKNOWN _ _ -_..-.�..��.-.,_,._. __.. _ 4 - 7.STEEL+INTERNAL LINING ❑95.UNKNOWN ❑ 99.OTHER(S ifyy: 444a SECONDARY CONTAINMENT Q'I.STEEL OM.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER 0 7.JACKETED 445• Q 90.NONE ©95.UNKNOWN ❑99.OTHER(S i ): 445L OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT FILL TUBE SHUT-OFF VALVE 4S2 13 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION E UIPMENT V. PRODU T/ WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION I.SINGLE WALL _ 2.DOUBLE WALL 99.OTHER 460. SYSTEM TYPE _ - - i.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR¢2636(!(3_�_- 458. PRIMARY CONTAINMENT (.STEEL 4.FIBERGLASS ❑ 8 FLEXIBLE 0 10.RIGID PLASTIC 464, ❑ 90.NONE ❑ 95.UNKNOWN [ 94 OTHER(Speckly): gyga SECONDARY CONTAINMENT ❑ 1.STEEL 4. IB FERGLASS ❑ 8.FLEXIBLE [0.RIGID PLASTIC 4W. (�90.NONE Q 95.UNKNOWN ❑ 99.OTHER(Specify) a64a P[PCNG/fURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL90.NONE 4644 VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ie1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC Q 90.NONE 13 99.OTHER(Specify): 464, VENT SECONDARY CONTAINMENT 13"1.STEEL 0 4.FIBERGLASS Q 10.RIGID PLASTIC (390.NONE Q 99.OTHER(Spwiky). 4641. 464Fl. VR PRIMARY CONTAINMENT U1 STEEL Q 4,FIBERGLASS ❑ 10,RIGID PLASTIC 0 90,NONE Q 99,OTHER(Speci[y): 4=1VR SECONDARY CONTAINMENT Q L STEEL Q 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ NONE ❑ 99,OTHER(Specify): 464k _ 464hE. VENT PIPING TRANSITION SUMP TYPE �,SINGLE WALL ❑2.DOUBLE WALL 90.NONE 464i. RISER PRIMARY CONTAINMENT QrI.STEEL Q 4.FIBERGLASS ❑ 10.RIGID PLASTIC [] 0,NONE Q 99.OTHER{Specify): -�4'444+. RISER SECONDARY CONTAINMENT (31.STEEL Q 4.FIBERG ASS E] [0.RIGID PLASTIC 90,NONE ❑ 99.OTHER(Specify): F[LL COMPONENTS INSTALLED I.SPILL BUCKET 3.STRIKER PLATEJBQTTOM PROTECTOR 4.CONTAINMENT464k1 _ SUMP d la•c, VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE _ 1.SINGLE WALL 2.DOUBLE WALL 3.N0 DISPENSERS 13 90,NONE 469a CONSTRUCTION MATERIAL STEEL ❑4.FIBERGLASS C3 10,RIGID PLASTIC 1399.OTHER(Specify) 4656. 469c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION U.1.SACRIFICIAL ANODES 4.IMPRESSED CURRENT b.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 m a with le al r ukrementa. APPLICANT SIGNATU _ DATE _ _ 476 APPLICANT NAME(prin 771 APPLICANT TITLE 472. UPCF UST-8 Rev.(I212DD7)-112 www.unidocs.org