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0 0-1 1� v1 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK ) OPERATING PERMIT APPLICATION-TANK INFORMATION (one form per UST) TYPE OF ACTION (Check one item only Fora UST closure or removal,complete only section ad S=cion l ll,Ill,!V and IX below) u0. ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ER S.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE UST DS.UST REMOVAL DATE UST PERMANENTLY CLOSED; ao4. DATE EXISTING ISCOVERED: 4306. FACILITY IDH(Agency Use Only) BUSINESS NAME(Same as Faci ityName or DBA-Doing Business As) 3. - �i-�.,J.1�.! ?e o le v.a *I coo BUSINESS SITE ADDRESS to CITY I 104.I o �.�►,�o V� P TANK ID. A C 432. TANK MANUFACTURER 433, TANKCONFIGURATION:THIS TANK IS 434 KIl _.rA- J Co err J 3 G o CEJ L A STAND-ALONE TANK Qaa*W.M.II 2.ONEINA COMPARTMENTED UNIT aavan.tle[hewit DATE UST SYSTEM INSTALLED 435. TANK CAP IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. TANK USE X Ia.MOTOR VEHICLE FUELING ❑ ]b.MARINA FUELING ❑ to.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(I, .&d Um oro ❑ S.EMERGENCY GENERATOR FUEL[HSC p5251.5(e)1 - ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER SSpedt): A19� CONTENTS PETROLEUM: ❑ Ia.REGULARUNLEADED ❑ Io.MIDGRADE UNLEADED El lb.PREMIUM UNLEADED ao. Gat 3.DIESEL ❑ 5.JEr FUEL ❑ 6.AVIATION GAS LJ &PETROLEUM BLEND FUEL ❑ 9,ORP PETROLEUM(Sped : 4a0e. NON-PETROLEUM:❑ 7.USED OR, ❑ 10.ETHANOL El 1I.OTHERNON-PETROLEUM(Specify): 440b TYPE OF TANK _-__❑ 1.SINGLE WALL R 3.DOUBLE WALL ❑ 95.UNKNOWN 443. PRQvIARY CONTAINMENT EL 1.STEEL- ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 4a4. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHERS�It 4a44. - SECONDARY CONTAINMENT ❑ I.STEEL IR,3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN E]99.00HER Sgxity): OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS -95 BALL FLOAT K 3.PILL TUBE SHUT-OFF VALVE 452. 4.TANK MEETS RE IJ1REa¢NTS FOR EXEMPTION FROM OVERFILL PREVENTION HOUIEMENT PIPING CONSTRUCTION _❑ 1.SINGLE WALL 5 2.DOUBLE WALL 99,OTHER 460. SYSTEM TYPE ----_-_ ®.1 PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 cae 41636(,_ xnl 45e. PRIMARY CONTAINMENT ❑ 1.STEEL 19 4.FIBERGLASS ❑ S.FLEX®LE ❑ 10.RIGIDPLASTIC 464 ❑ 9o.NONE ❑ 95.UNKNOWN El 99.OTHER 3 464a. SECONDARY CONTAINMENT [] 1.STEEL Q 4.FIBERGLASS ❑ 9.FLEXIBLE ❑ to.Rim PLASTIC - 464b. ❑ 90.NONE ___[3_95.UNKNOWN --C]-9!CT!2R(Specify): 464. PIPING/TURBINE CONTAINMENT SUMP TYPE ._. C&1.SINGLE WALL ❑ 2.DOUBLE WALL [] 9D.NONE 4644, VENT PREWARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE 1399.OTHER(Specify): 461e. ----- 464e1. VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46ae 4 . VR PRIMARY CONTAINMENT ❑ I.STEEL R a.FIBERGLASS ❑ 10.RIGID PLASTIC 090.NONE ❑ 99.OTHER(Specify): Z VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS _ ❑ IURIGIDPLASTIC [190.NONE ❑ 99.OTHER(Specify): 464b1. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 1190.NONE ' RISER PRIMARY CONTAINMENT ❑ 1.STEEL Q 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify); 4647 4. RISER SECONDARY CONTAINMENT M 1.STEL L ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑99.OTHER(SpecRy): 464'k FILL COMPONENTSINSTALLED - -SPH.LBUCKFT -ffj.STRUM PLATEMOTTOM PROTECTOR ❑ 4.CONTAINMBNTSUMP 451a.c. :CONSTRUCTION UCTION TYPE L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NODISPENSERS ❑ 90.NONE 469n MATERIAL �I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 99.OTHER(*city) 46991 469c. STEEL COMPONENT PROTECTION ❑ 2c SACRIFICIALANODH(S) 4.IMPRESSED CURRENT 6.ISOLATION 447. 25 all 111111 CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate,RUMfull com ncc with legal requirements. APPLICANT SIGNATURE DATE /® /'.� / 479. APPLICANT NAME(print) 47I. APPLICANT TITLE 412. N� UPCF UST-B Rev.(12/2007)-112 www.unidocs.ore