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UPCF UST -B -1R' Rev. (1212007) UNIFIED PROGRAM CONSOLIDATED FORM I UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (one form U 1 per n -TE OF ACIION (Check one item only. FN,sn UST permanent closure orremoval, complete only this Section and Sections L II, III, IV, and IX below) 0 1. NEW PERMIT 450 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION 6. TEMPORARY UST CLOSURE 7. UST PERMANENT CLOSURE ON SITE 8. USi REMOVAL DATE UST PERMANENTLY CLOSED: 4JN DATE EXISTING UST DISCOVERED: 4506 FACII.ITY ID # (Agency Use Only) - s BUSINESS NAME (Same as FACILITY NAME or DBA•Doing Busiraxs As) I. 3 BUSINESS SITE ADDRESS ,i m CITY S/ OG f� .✓i 5.9� To.✓ IN �y�/� TANK ID # �► 431 TAAN,& MANE IFALTURER 433 TANK CONFIGURATION THIS TANK IS CII�/� �Y ` 4N VWC.��S A STAND-ALONE TANK 171\ 0 \J . ONE IN A COMPARTMENTED UNIT . S DATE UST SYSTEM STALLED 435 ��aaammm deme for eachI I,ntk.L C[N TANK CAp�CT[y (SJ CA�1 ONS 4M NUMBER OF (�l) JARJ,T�N]'S IN THE IT 4n �❑ TANK USE 41.. MOTOR VEHICLE FUELING Ib.MARINA FUELING ❑ Ie AVIATION FUELING 439 [3 5. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE Beclued Used Off) ❑ 5. EMERGENCY GENERATOR FUEL (HSC 175281.5(.)] ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN [T99. OTHER (Specify): 43% CONTENTS PETROLEUM: ❑ 11. REGULAR UNLEADED ❑ It. MIDGRADE UNLEADED ❑ 1b. PREMIUM UNLEADED 440 $7. DIESEL ❑ 5. )ET FUEL ❑ 6. AVIATION GAS ❑ R. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM(Specify): NON-PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL 440a _ 11. OTHER NON-PETROLEUMS eci 440b - TANK L SINGLE WALL 2. DOUBLE WALL ❑ 95. UNKNOWN PRIMARY PRIMARY CONTAINMENT ❑ LSTEEL �T. FIBERGLASS ❑ 6. INTERNAL BLADDER 443 ❑ 7. STEEL INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER S 444 ci SECONDARY CONTAINMENT ❑ 1. STEEL . FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7.1gCKETED 444a as ❑ 90. NONE -- ❑ 95. UNKNOWN 099. OTHERS eci 445. OVERFILL PREVENTION . AUDIBLE& VISUAL ALARMS 0 2.BALLFLOAT3. FILL TUBE SHUT-OFF VALVE ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM 451, .. OVERFILL PREVENTION EQUIPMENT , PIPING CONS TRUCTION ❑1.SINGLE-WALLED id 2. DOUBLE-WALLED ❑99. OTHER c SYSTEM TYPE . 1. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION 13= 2636(.x3) - 460 458 PRIMARY CONTAINMENT I, STEEL 4. FIBERGLASS ❑ S. FLEXIBLE ❑ 10. RIGID PLASTIC 464 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER(Specify): ,(] 4M. SECONDARY CONTAINMENT L STEEL 4, FIBERGLASS ❑ B. FLEXIBLE 10. RIGID PLASTIC 4Mb ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.0THER (S e<ify): 46ec PIPTNG/TURBINE CONTAINMENT SUMP TYPE ❑LSMGLE WALL B-i:DOUBLE WALL 90. NONE 464d VENT PRIMARY CONTAINMENT IT1. STEEL _ 4. FIBERGLASS u 10. RIGID PLASTIC LJ 90. NONE U 99 OTHER (Specify) 464e VENT SECONDARY CONTAINMENT I.STEEL-.FIBERGLASS IO. RIGID PLASTIC 90. NONE 99. OTHEReci (SP M 4 46,11' VR PRIMARY CONTAINMENT 1.S7EEL 19 4.FIBERGLASS10. RIGID PLASTIC 90. NONE 99.OTHER (specify) 6,111 44648 VR SECONDARY CONTAINMENT L1 I. STEEL :FIBERGLASS 10. RIGID PLASTIC 90. NONE 99. OTHER S e� (p dy) 4464h VENT PIPING TRANSITION SUMP TYPE I. SINGLE WALL46161 OUBLE WALL 90. NONE 4641. RISER PRIMARY CONTAINMENT .STEEL U 4. FIBERGLASS U 10. RIGID PLASTIC U 90. NONE 99. OTHER (Specify) 464j RISER SECONDARY CONTAINMENT . STEEL U 4. FIBERGLASS 11 10. RIGID PLASTIC U 90. NONE U 99. OTHER (Specify) 464'1 464k FILL COMPONENTS INSTALLED 'I. SPILL BUCKET 3. STRIKPPL�A�TEBOTTOM PROTECTOR 4. CONTAINMENT SUMP Mkt 451a-c pER IAN R, IN CONSTRUCTION TYPE ❑ 1. SINGLE W ALL y�.DOUBLE WALL ❑ ]. NO DISPENSERSf ❑ 90. NONE 469a CONSTRUCTION MATERIAL 1. STEEL 4. FIBERGLASS 0. RIGID PLASTIC ❑ 99. OTINER S eci 469b< yy STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIALANODE(S) ❑ 4. IMPRESSED CURRENT 6. ISOLATION 445. CERTIFICATION: 1 certify that ones UST system Is compatible with the haurdous mbstance stored and that the information provided herein Is true, accurate, and in full com I ce with 1 al re uirements. APPLICANT SIGNATURE -/ DATE 470 471 APPLICANT NAME (print) !,' APPLICANTT E 472. A.� L .ter � m ee%1 E/L UPCF UST -B -1R' Rev. (1212007)