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- gp Lol UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK FADD 1 D 33y OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 4 11,111,N,and IX below) 430. ❑ L 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: 430• DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ _ 1. BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. BUSINESS SITE ADDRESS 103 CITY 104_ II. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434 ❑ 1.A STAND-ALONE TANK ce,n J.oae page for each ❑ 2.ONE IN A COMPARTMENTED UNIT wmpoeeees ie 0,e era DATE UST SYSTEM INSTALLED 435 1 TANK CAPACITY IN GALLONS 436- NUMBER OF COMPARTMENTS IN THE UNIT 437 50040 III. TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ I..AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE �Igsa4.HAZARDOUS WASTE(Includes Used u) ❑ 5.EMERGENCY GENERATOR FUEL RISC 625281.58)] ❑ 6.OTHER GENERATOR FUEL [1 95.UNKNOWN ❑ 99.OTHERS eci 439& -_.- .._.. -........_._____ CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADEDD ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 449_ ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 44M NON-PETROLEUMA%7.USED OIL ❑ 10.ETHANOL ❑ I L OTHER NON-PETROLEUMS eci : 4406. IV. TANK CONSTRUCTION TYPE OF TANK _ ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 95.UNKNOWN 443. PRIMARY CONTAINMENT ❑ L STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444% SECONDARY CONTAINMENT ❑ 1.STEEL [13.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ T JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Spsify_} 445. OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL 0 2,DOUBLE WALL [.99.OTHER 460, SYSTEM TYPE ❑ I PRESSURE Ej 2 GRAVITY -b I CONVENTIONAL SUCTION__❑ 4 SAFE SUCTION L23 CCR¢2636(�L_ 458. PRIMARY CONTAINMENT [31.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(S ci ): 464. SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 461c. PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ I0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 0TN VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS 0 10,RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46t4P1 VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): a41 s' VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 44Mh' VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 06°'' RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 1' RISER SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): °64 464k1. FILL COMPONENTS INSTALLED ❑ I.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451.-1. VII. UNDER DISPENSER CONTAINMENT(UDC) _CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOl1 BLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469% CONSTRUCTION MATERIAL ❑ I STEEL ❑ 4 FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 99.OTHER(Spee4y) % 46 VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.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 compliance with legal requirements. APPLICANT SIGNATURE DATE 470' APPLICANT NAME(print) 471 APPLICANT TITLE °Yt UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org