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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. For.anlAST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 430 ❑ I.NEW PERMIT 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: °J°a DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) I- BUSINESS AME(Same as FACILITY�A�MEor nlllg 'siness ) .G �nb 'JU19 T9A%j ' P AA 3 06 ft Gr jr}, N Y N1 W P" AA SITE ADDRESS Ct Q A k3 VD CfI'Y .�Ln,., O 1°° *1 IIttTANK�DESCRIPTION '-TIT`�+7 TANKIDN 432 TANK MANU1F,ACTU'/R"trEAR(' 0433 TANK CONFIGURATION: THIS TANK IS 434 l l `D SO-7 I Li > mcoekh) `r - jr ��IJ�N O�,ASTAND-ALONE TANK FQ? ONE M A COMPARTMENTED UNIT. Com lmme eforeechcom m tin Neurit DATE UST SYSTEM INSTALLED 435 TANK CAPACITY LLONS °36 NUMBER OF COMPARTMENTS IN THE UNIT 437 O'I III.TANK USE AND CONTENTS TANK USE fijla.MOTOR VEHICLE FUELING ❑ It, MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE u.Wdes Used oio ❑ 5.EMERGENCY GENERATOR FUEL IHSC§25281.5(c)I ❑ 6.OTHER GENERAT FUEL [195.UNKNOWN El 99.OTHER(Specify): 439. CONTENTS PETROLEUM: 5. e.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUMUNLEADED M0 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11,OTHER NON-PETROLEUM(S eci : 440b . TANK CONSTRUCTION TYPE OF TANK ❑ L SINGLE WALL GrfipU-BLEWALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ I.STEEL b44.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL NTNG ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444e SECONDARY CONTAINMENT ❑ 1.STEEL LZ3.FIBERGLASS ❑ 6.EXTERIOR MEMBRA LINER El 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN El 99.OTHER(Sp.i 4454 OVERFILL PREVENTION ❑ I.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMP'HON FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ .SINGLE-WALLED &r2.DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§M3(4.x3)I 459 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ .UNKNOWN [199.OTHER(Specify): 4Mc PIPINGITURBINE CONTAINMENT SUMP TYPE Ey 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464E VI.VENT,VAPO COVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1 STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4(Ae 64e1 VENT SECONDARY CONTAINMENT I.STEEL ❑ 4 FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT ❑ L STEEL .FIBERGLASS ❑ HL RIGID PLASTIC 90,NONE 99.OTHER(Specify) 4646 441 VR SECONDARY CONTAINMENT ❑ L STEEL 4 V d 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ .NONE El 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ .SINGLE WALL 2.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 9 .NONE ❑ 99.OTHER(Specify) 4641 46411 RISER SECONDARY CONTAINMENT I.STEEL [14.FIBERGLASS [110.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) bebk 464k] FILL COMPONENTS INSTALLED Dd I.SPILL BUCKET 0 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451.< UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE L SINGLE WALL ❑ 2 OUBLE WALL ❑ 3.NO DISPENSERS EJ 90,NONE 469a CONSTRUCTION MATERIAL L11.STEEL El 4.FIBERGLASS 0.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that is UST system is compatible with the hazardous substance stored and that the information provided herein is _e,accurate, and in full c pliaricewth ftal requirements. Z, APPLICANT SIGNATURE DATE o3 ,G �+q , 470' APPLICANT NAME(print) 471. APPLICANT TITLEQ. 4+"L` 472, &TAP, 51A041 UPCF UST-B-1/2 .a Rev.(12/2007)