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UNIFIED PROGRAM CONSOLIDATED FORM ( I \ UNDERGROUND STORAGE TANK l 1C O OPERATING PERMIT APPLICATION - TANK INFORMA (one form per UST) 'IpL1t -PE OF ACTION (Check one item only. Fo• an UST permanent closure orre noval, complete only this section and Sections 1, ll, IB, IV, and IX below) 430 C3. 1. NEW PERMIT 3. RENEWAL PERMIT ❑. 5. CHANGE OF INFORMATION 6. TEMPORARY UST CLOSURE 7. UST PERMANENT CLOSURE ON SITE K- 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 12-01-1.3 43a DATE MaSTING UST DISCOVERED: 430b FACILITY ID # (Agency Use Only) BUSINESS NAME (Same as FACILTIY 3 piBAD Vi -j - - BUSINESSSITEADDRESS Ins CITY .yo�G IN TANK ID # 433 TANK MANI IFACTURER 43 CONFIGURATION: THIS TANK IS C6?'Z J'Ar/3�STAND-ALONE 4x TANK HE RI A COMPARTMENTED UNIT. F/ 6<9S Com ee oca MULM each coeepannecue in dbe emit DATE UST SYSTEM -INSTALLED 435 TANK CAPACITY NOA.LONS 436 NUMBER OF �AMjART, jS IN THE ff LC 437 1vv (l / ((//C✓ TANK USE la. MOTOR VEHICLE FUELING ❑ Ib. MARINA FUELING ❑ Ic. AVIATION FUELING439 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE(belulas Un all ❑ 5. EMERGENCY GENERATOR FUEL NSC 125281.5(c)I ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN 0'99. OTHER (Specify): 439, CONTENTS PETROLEUM: b. REGULAR UNLEADED ❑ Ic. MIDGRADE UNLEADED ❑ Ile. PREMIUM UNLEADED 440 • DIESEL 5. JET FUEL [36. AVIAT O GAS ❑ S. PETROLEUM BLEND FUEL 9. OTHER PETROLEUM(specify): '' nn Yl-/ D �� 44W NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL II. OTHER NON -PETROLEUM S mi 440b r� Crp Ti L " ,''f1'9` : TYPEOFTANK ❑LSINGLE WALL 2. DOUBLE WALL 095. UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1. STEEL WO. FIBERGLASS ❑ 6.INTERNALHLADDER 444 ❑ 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHERS eci 444, SECONDARY CONTAINMENT ❑ 1. STEEL .FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. METED 445 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER S eci 443, OVERFILL PREVENTION .AUDIBLE&VISUALALARMS 2. BALL FLOAT 3. FILL TUBE SHUT-OFF VALVE 452. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT t:-.PIING`CONSTRUCTION� PIPING CONSTRUCTION ❑ 1. SINGLE -WALLED 2. DOUBLE -WALLED ❑ 99. OTHER 460 SYSTEM TYPE ❑ I. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION F23 CCR§206(.X3)1 458 PRIMARY CONTAINMENT de 1. STEEL 4. FIBERGLASS ❑ S. FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER(Specify): 46aa SECONDARY CONTAINMENT ❑ 1. STEEL 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 4Mb ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 4Mc PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ I. SINGLE WALL Q=t: DOUBLE WALL ❑ 90. NONE 464d VI VEN1s. . /�A'I tO, ),A}�Il`RISPR/ FILL PIPE PIPING t6NSTR"IICTI6N, , VENT PRIMARY CONTAINMENT C7 1. STEEL 4. FIBERGLASS LI 10. RIGID PLASTIC 0 90. NONE C3 99. OTHER (Specify) 464, 464,1 VENT SECONDARY CONTAINMENT �. I. STEEL -4. FIBERGLASS 0 10. RIGIDPLASTIC 90. NONE ❑ 99. OTHER (Specify) 464f 4mn VR PRIMARY CONTAINMENT G ].STEEL . FIBERGLASS 0 10. RIGID PLASTIC ❑ 90. NONE t3 99. OTHER (Specify) 4646 II VR SECONDARY CONTAINMENT I. STEEL . FIBERGLASS Ll 10. RIGID PLASTIC C3 90. NONE 99. OTHER (Specify) 4 464b 464h1 VENT PIPING TRANSITION SUMP TYPE Q I. SINGLE WALL7M.-DOUBLE WALL Q 90. NONE 4641. RISER PRIMARY CONTAINMENT . STEEL LJ 4. FIBERGLASS U l0. RIGID PLASTIC U 90. NONE 0 99. OTHER (Specify) 464j 464'1 RISER SECONDARY CONTAINMENT . STEEL 4. FIBERGLASS Ll 10. RIGID PLASTIC 90. NONE 0 99. OTHER (Specify) 4Mk 464k1 FILL COMPONENTS INSTALLED 1. SPILL BUCKET Ll 3. STRIKER PLATE/BOTrom PROTECTOR 0 4. CONTAINMENT SUMP 451a -c VII. UNpER-DISPEN$ER,CQNTAINMEN,` ' --,, ,, , - . CONSTRUCTION TYPE ❑ I. SINGLE WALL &LDOUBLE WALL L13. NO DISPENSERS ❑ 90. NONE 46% CONSTRUCTION MATERIAL [11. STEEL [14ery 4. FIBERGLASS I0. RIGID PLASTIC ❑ 99.OTHER (Specify) 469b.c VIII. CORROSION PROTECTION+ STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT 0 6. ISOLATION 448. IX. APPLICANT SIGNATURE. CERTIFICATION: I certify that th(s,UST system is compatilde w(th the hazardous substance stored and that the information provided herein is true, accurate, and In full co ante with legaLAquirements. APPLICANT SIGNATURE DATE L - t�5� �/3 470 APPLICANT NAME (print) 471'APPLICANTT E 4n� AnJ/ 6G o st O e%f E /L UPCF UST -B -1/2 Rev. (12/2007)