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n L J 11 11 a a UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK 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 Sec 'ons 1. IL 111. If C and IX below) 430. F-11. NEW PERMIT El 3. RENEWAL PERMIT Z- 5. CHANGE OF INFORMATION ❑ 6. TEMPORARY UST CLOSURE ❑ T UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 430. 1 DATE EXISTING UST DISCOVERED'. 4306 I. FACILITY INFORMATION FACILITY ID 4 (Agency Use Only) L BUSINESS NAM (Same as Facility Name or DBA - Doing Business As) 3. ��x .J ain ori -e TrG+u�� isfi«-J� BUSINESS SITE ADPRESS 103- CITY I W. II. TANK DESCRIPTION TANK ID 432. )Vo r7 - %AOl1Sd'�� TANK MANUFACTURER J33 d/ eax a" �/ TANK CONFIGURATION. THISTANKIS 434. 0I ONE INA COMPARTMENTED cvcComprveonepege foils ❑ 2. ONE INA COMPARTMENTED UNIT Compayte one heunie DATE UST SY$TE STALLED 435. 4 1 TANK CA�ACIITYQN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. M. TANK USE AND CONTENTS TANK USE ❑ Ia. MOTOR VEHICLE FUELING ❑ Ib. MARINA FUELING ❑ Ic. AVIATIONFUELING 439. ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 5. EMERGENCY GENERATOR FUEL p4SC §252815(c)] El6.OTHER GENERATOR FUEL ❑ 95. UNKNOWN 99. OTHER (Spec n;p Qs��,jt/t7p! 439.. �.............- CONTENTS PETROLEUM: ❑ Ia. REGULAR UNLEADED ❑ Ic. MIDGRADE UNLEADED ❑ Ib. PREMIUM UNLEADED a40_ ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM 440. NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHNOT. X I1. OTHER NON -PETROLEUM (Specify}. / �'"o �r 49d 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ I. SINGLE WALL 2. DOUBLE WALL ❑ 95. UNKNOWN 443. PRIMARY CONTAINMENT ❑ 1. STEEL 93. FIBERGLASS ❑ 6. INTERNAL BLADDER 444. ❑ 7. STEEL INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER . _.. _ _...__.. -.P..._. SECONDARY CONTAINMENT ❑ 1. STEEL ,IfQ3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. 7. JACKETED 445_ ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 445% OVERFILL PREVENTION ❑ I. AUDIBLE &VISUAL ALARMS ❑ 2. BALL FLOAT 9 3, FILL TUBE SHUT-OFF VALVE 452_ ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT / WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ I. SINGLE WALL 2. DOUBLE WALL ❑ 99. OTHER 460. SYSTEM TYPE ❑ 1. PRESSURE ❑ 2. GRAVITY Zf 3. CONVENTIONAL SUCTION ❑ 4_SAFE SUCTION 123CCR§2636(a)(3)]. 458. PRIMARY CONTAINMENT ❑ 1. STEEL X L FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464. ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER(Spcaly): 464% SECONDARY CONTAINMENT ❑ I STEEL ❑ 4 FIBERGLASS ❑ 8 FLEXIBLE ❑ 10. RIGID PLASTIC. 4646. __ ❑ 90 NONE ❑ 95 UNKNOWN ___�99 OTHER(Spee'fy) O /t✓Ja Bump . h✓ ed�°M4- 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 ,,�( 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify). 46441. VENT SECONDARY CONTAINMENT Lry 1. STEEL ❑ 4. FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify). 46 n _. _ --_-__-___.._......._........_._-._.___.__.._.________._-____.___... VR PRIMARY CONTAINMENT Eq 1. STEEL ❑ 4. FIBERGLASS ❑ UL RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 46445- 11 VR SECONDARY CONTAINMENT [Z L STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 464hL VENT PIPING TRANSITION SUMP TYPE ❑ L SINGLE WALL ❑ 2. DOUBLE WALL L&90. NONE °M` RISER PRIMARY CONTAINMENT U. 1. STEEL ❑ 4 FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 464°i' V.&I. RISER SECONDARY CONTAINMENT A L STEEL ❑ 4. FIBERGLASS El 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify). FILL COMPONENTS INSTALLED J9 I. SPILL BUCKET ❑ 3. STRIKER PLATE/BOTTOM PROTECTOR ❑ 4. CONTAINMENT SUMP 45m -c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ❑ I. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS X90, NONE 469. CONSTRUCTION MATERIAL ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 469b VIII. CORROSION PROTECTION MOW= STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODES) ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION 6. IX. APPLICANT SIGNATURES CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein i}truem accurate, an ' u11 ectmPlianAwith le 1 requirements, APPLICANT SIGNATUREDATE 7114109 APPLICANT NAME (print) � Oh d71' APPLICANT TITLE ILL-�GiT.�'S dipa/�nyt�i4„ t a. T4 UPCF UST -B Rev. (12/2007).1/2 www.unidocs.org j