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• • • r-1 C1 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 Sections 1, 0, 10, 1V, and IX below) 430 ❑ 1. NEW PERMIT ❑ 3. RENEWAL PERMIT I$ 5. CHANGE OF INFORMATION (uCM) E]6. TEMPORARY UST CLOSURE [-17. UST PERMANENT CLOSURE ON SITE 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 13a). DATE EXISTING UST DISCOVERED: 4306, I. FACILITY INFORMATION FACILITY ID 4 (Agency Use Only) - 1. BUSINESS NAME (Same as Facility Name or DBA- Doing Business As) 3. S42^J OIG V 1 n 4on@Q BUSINESS SITE ADDRE 103. /5'33 E. Lf.,d s7' CITY 194. S'te5ek7Drl U. TANK DESCRIPTION TANK ID 4 ��ppO (( 1p 432_ Qa'- Qs7Q� J TANK MANUFACTURER 433- C� Dw�/%5 �•/l�n 0 TANK CONFIGURATION: THIS TANK IS 434. X-1. ASTAND-ALONE TANK Compineone pageforwch ❑ 2. ONE M A COMPARTMENTED UNIT mana,unmt in the wit. DATE US; SYSTEM INSTALLED 435. li49 L- TA CAPACITY IN GAL ONS 435. , a 19 NUMBER OF COMPARTMENTS IN THE UNIT 437 All -A, III. TANK USE AND CONTENTS TANK USE Ia. MOTOR VEHICLE FUELING ❑ Ib. MARINA FUELING ❑ 1.. AVIATION FUELING 439. ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (N6.&, Uw4 Oi) ❑ 5. EMERGENCY GENERATOR FUEL[HSC§252815(c)] ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439. CONTENTS PETROLEUM: ❑a�r 1.. REGULAR UNLEADED ElIc MIDGRADE UNLEADED ❑ Ib. PREMIUM UNLEADED "a 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS Jea. ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (Specify): 440. NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ❑ 11 OTHER NON -PETROLEUM (Specify): 4406. IV. TANK CONSTRUCTION TYPE OF TANK ❑ L SINGLE \\ ALI. g2. DOC TILE WALL El95. UNKNOWN 443 . PRIMARY CONTAINMENT ❑ I. STEEL 'i 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444. Dc ❑ 7. STEEL+ INTERNAL LINING ❑ 95. UNKNOWN ❑ 99.OTHER (Specify): SECONDARY CONTAINMENT ❑ I. STEEL 21.3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445. ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 445% OVERFILL PREVENTION ❑ 1. AUDIBLE & VISUAL ALARMS ❑ 2. BALL FLOAT OK 3. FILL TUBE SHUT-OFF VALVE 452. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT / WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION _ _0 1. SINGLE WALL 2. DOUBLE WALL EI 99. OTHER 450. SYSTEM_ TYPE J, I. PRESSURE 2. GRAVITY El 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION 23 CCR §206(m)(3)]458. �❑/ PRIMARY CONTAINMENT El 1, 1. STEEL 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 454 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464. _ SECONDARY CONTAINMENT ❑ 1. STEEL Cr 4. FIBERGLASS ❑ S. FLEXIBLE ❑ 10. RIGID PLASTIC 4646. ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER (Speoify)'. 464° PIPING/TURBINECONTAINMENT SUMP TYPE ❑ 1 SINGLE WALL X2. DOUBLE WALL ❑ 90. NONE 4644 VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1p 1. STEEL [14. FIBERGLASS El 10.RIGIDPLASTIC EI90. NONE ❑ 99. OTHER (Specify): 4644ej' VENT SECONDARY CONTAINMENT J!I 1. STEEL El4. FIBERGLASS El 10, RIGID PLASTIC [190. NONE El99. OTHER (Specify): 446448 VR PRIMARY CONTAINMENT 9 1. STEEL ❑ 4. FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99. OTHER 44a, VR SECONDARY CONTAINMENT 9 L STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE E-1-99. OTHER(Specify): 464hI VENT PIPING TRANSITION SUMP TYPE ❑ [.SINGLE WALL ❑ 2 DOUBLE WALL 90. NONE 064` RISER PRIMARY CONTAINMENT J. 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify); 4M, 464 1. ,d RISER SECONDARY CONTAINMENT 9-1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 46gkI' FILL COMPONENTS INSTALLED I. SPILL BUCKET ❑ 3. STRIKER PLATEBOTTOM PROTECTOR ❑ 4. CONTAINMENT SUMP 45la-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE L SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 469. CONSTRUCTION MATERIAL ❑ I. STEEL ❑ 4. FIBERGLASS 10. RIGID PLASTIC ❑ 99. OTHER (Specify) b. VIII. CORROSION PROTECTION - -- STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION ry. 9. d IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein 3YFne, ull com ance with legal requirements. C- 14 accurate, and' ' APPLICANT SIGNATURE 4m. DATE 7/G Iplp APPLICANT NAME (print) zc C on 471 �+ APPLICANT TITLE �czel; M ft.�Jpst 47z. UPCF UST -B Rev. (12/2007) -12 www.unidoes.org u