Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK L� � <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION cone fold p.,I ST) <br /> TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1.Ih ILL!V,and 1A below) 430. <br /> I.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430+ DATE EXISTING UST DISCOVERED: 430b. <br /> I. FACILITY INFORMATION <br /> FACILITY ID tJ(Agency Use Only) <br /> O <br /> PUSfNESS <br /> NAME(Same as Facility Name or DBA-Doing Business AS) <br /> 3. <br /> SITE ADDRESS �U3. CIfYII. TANK DESCRIPTION <br /> 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. <br /> `Q7 �1.A STAND-ALONE TANK Completeonepageforemb <br /> DATE UST SYSTEM INSTALLED ms. TANK CAPACITY IN GALLONS 43b, 0 2"ONE INA COMPARTMENTED UNIT mmpabomtin Mewit <br /> Z NUMBER OF COMPARTMENTS IN THE UNIT 437. <br /> III. TANK USE AND CONTENTS <br /> TANK USE ❑ [a.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING <br /> 0 3.CHEMICAL PRODUCT STORAGE 0 S.EMERGENCYUE NEEING 4l9 <br /> 4.UNKNOWN <br /> WASTE(Includes Used Oip ❑ S.EMERGENCYGENERATOR FUEL[HK§2528L5(c)I <br /> ❑ ROLEURGENERATOR FUEL ❑ 95.UNKNOWN 0 99,OTHER(Specify): 439. <br /> CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED 0 Ic.MIDGRADE UNLEADED 0 Ib.PREMIUM UNLEADED 44o. <br /> 0 3.DIESEL 0 5.JET FUEL 0 6.AVIATION GAS <br /> 0 8.PETROLEUM BLEND FUEL 0 9.OTHER PETROLEUM(Specify): ggpi <br /> NON-PETROLEUM:0 7,USED OIL ❑ 10.ETHANOL <br /> IL OTHER NON-PETROLEUM(S eci ) I1<L• n�„�� "ob, <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK �1,SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95 UNKNOWN 443 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 3.F®ERGLASS ❑ 6.INTERNAL BLADDER <br /> 444.- <br /> ❑ 7.STEEL+INTERNAL LMMG 95.UNKNOWN ❑ 99.OTHER(Specify): 444. <br /> SECONDARY CONTAINMENT ❑ L STEEL ❑3.FIBERGLASS ❑ b.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 <br /> ��90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 495a <br /> OVERFILL PREVENTION ❑ I.AUDIBLE$VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL NBE SHUT-OFF VALVE 452. <br /> ❑ 4.TANK MEETS RE UIREMEMS FOR EXEMPTION FROM OVERFILL PREVENTION ES2UIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION 7�'I.SINGLE WALL ❑ 2 DOUBLE WALL (] 99.OTHER 460 <br /> SYSTEM TYPE ❑ LPRESSDRE .GRAVITY 03.CONVENTIONAL SUCTION 04.SAFE SUCTION[23 CCR§26364)(3)] 458. <br /> PRIMARY CONTAINMENT 0 L STEEL 0 4.FIBERGLASS 0 8.FLEXIBLE <br /> ❑ 90.NONEi�10.RIGID PLASTIC 464. <br /> ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. <br /> SECONDARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS 0 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. <br /> _ ❑ 90.NONE 0 95 UNKNOWN A99,OTHER(Specify): q,,( 464c <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ I.SINGLE WALL 0 2.DOUBLE WALL Ad 90.NONE IMM. <br /> VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC B,90.NONE 0 99.OTHER(Specify): 4 <br /> VENT SECONDARY CONTAINMENT 46ac1 <br /> ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 469E <br /> VK PRIMARY CONTAINMENT464). <br /> ❑ I.STEEL ❑ 4,FIBERGLASS ❑ IO.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify): 4 <br /> 64 <br /> VR SECONDARY CONTAINMENT464et <br /> ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 19 90,NONE 0 99.OTHER(Specify); M6 <br /> VENT PIPING TRANSITION SUMP TYPE 4646E <br /> ❑ 1.SINGLE WALL 0 2.DOUBLE WALL R 90.NONE i. <br /> RISER PRIMARY CONTAINMENT ❑ I,STEEL 04.FIBERGLASS O IO.RIGID PLASTIC �,9p.NONE ❑ 99.OTHER(Specify): <br /> RISER SECONDARY CONTAINMENT4� <br /> ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ES 90.NONE [199.OTHER(Specify), 461 <br /> k <br /> FILL COMPONENTS INSALLED ❑ I.SPILL BUCKET 464-c <br /> ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 0.CONTAINMENT SUMP 451 a-c <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ❑ L SINGLE WALL 0 2.DOUBLE WALL 3.NO DISPENSERS <br /> ❑ 90.NONE 469. <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) t <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION 0 2.SACRIFICIAL ANODE(S) 0 4.IMPRESSED CURRENT 0 6.ISOLATION <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, <br /> accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 470. <br /> APPLICANT NAME(print) 4J1' APPLICANT TITLE 472. <br /> UPCF UST-B Rev.(12/2007)-I/2 www.unidoc"rg <br />