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UPCF UST -11 -1/2 Rev. (12/2007) UNIFIED PROGRAM CONSOLIDATED FORM 1 UNDERGROUND STORAGE TANK l 12 OPERATING PERMIT APPLICATION -TANK INFORMATION' (One form pwuSNV ^'PE OF ACTION (Check one item only. Fw-an UST pemunent closure or mmoval, complete only this secWn and Section I, D, N. N, and IX below) f I. NEW PERMIT3. )4 0 RENEWAL PERMIT NREMCORMATION 6. TEMPORARY UST CLOSURE 7. UST PERMANENT CLOSURE ON SITE 51 S. UST DATE UST PERMANENTLY CLOSED: 450. DATE EXISTING UST DISCOVERED: 430b FACILITY ID#(Agency Use Only) _ 4 �''-ws'. ""I""``•. :...•� . BUSINESS NAME (Same as FACILITY NAME or DBA -Doing BusitJas N) 5 S t//,J / b�� /✓s % 7 BUSINESS SITE ADDRESS f, .✓/ 5.9� m CITY ., .,., _ ......_... L _.. TANK lD# 432 455...f RATION THIS TANK IS '{�2 TvWGivs 434 t_-GR,2E�/�� LONE TANK F[� aC,{GCA emsW COMPARTMENTED UMT DATE UST SYS �P1SALLED 455 a eech 4n Ute TANK CAp�CTSy gd SfA[,LONS 436 NUMBER OF SAMfAR�Na'S IN THE IN 1T p( C/(JOO / 4 n _ 4 i'0 TANK USE a. MOTOR VEHICLE FUELING 0 Ib. MARINA FUELING Ic AVIAT70N FUELING - M 439 0 3. CHEMICAL PRODUCT STORAGE 0 4. HAZARDOUS WASTE (IMudv Used Oi0 ❑ 5. EMERGENCY GENERATOR FUEL (HSC 425281.5(c)J ❑ 6.OTHER GENERATOR FUEL 0 95. UNKNOWN [199. OTHER (Specify): 459. CONTENTS PETROLEUM: 11 18. REGULAR UNLEADED 0 Ic.MIDGRADEUNLEADED 0 Ib. PREMIUM UNLEADED 440 .$-a. DIESEL 05. JET FUEL 06. AVIATION GAS ❑ a. PETROLEUM BLEND FUEL 0 9. OTHER PETROLEUM S eei : 44of NON -PETROLEUM: Lj 7. USED OIL 0 10. ETHANOL LOTHE.R NON -PETROLEUM S cci 4406 TYPEOF ANKCON 1. SINGLE WALL 2. DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1. STEEL 5 1. FIBERGLASS 0 6. INTERNAL BLADDER ❑ 7. STEEL + INTERNAL LINING 0 95.IINKNOWN ❑ 99. OTHER S 444 cJ SECONDARY CONTAINMENT ❑ i. STEEL .FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 444. 445 ❑ 90. NONE -- ❑ 95. UNKNOWN ❑99.OTHHR (Spec 4458 OVERFILL PREVENTION . AUDIBLE d VISUAL ALARMS 2. BALL FLOAT 5. FILL TUBE SNOT -OFF VALVE 452. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT -� - !.-. -' ,.. .I --.-- f .. .� 8 PIPING CONSTRUCTION ❑ L SINGLE -WALLED 2. DOUBLE -WALLED 0 99. OTHER 460 SYSTEM TYPE 0 1. PRESSURE 0 2. GRAVITY 0 J. CONVENTIONAL SUCTION 0 4. SAFE SUCTION In CCR 6206(.X3)1 458 PRIMARY CONTAINMENT1. STEEL 4. FIBERGLASS 0 S. FLEXIBLE 0 10. RIGID PLASTIC 464 0 90. NONE 0 95. UNKNOWN ❑ 99.OTHER(Specify): 464. SECONDARY CONTAINMENT 0 1. STEEL d. FIBERGLASS ❑ B. FLEXIBLE ❑ 10. RIGID PLASTIC 46gb 0 90. NONE 0 95. UNKNOWN 0 99. OTHER (Specify): 4Mc PIPING/TURBINE CONTAINMENT SUMP TYPE 0 1. SINGLE WALL (x2: DOUBLE WALL ❑ 90. NONE 4644 s ,5�. e. , - -l. N z STEEL t. FIBERGLASS 10. RIG VENT PRIMARY CONTAINMENT ID PLASTIC 90.NONE 99.OTHER(Specify) 464c VENT SECONDARY CONTAINMENT .1. STEEL - .FIBERGLASS 10. RIGID PLASTIC 90. NONE 99. OTHER (Specify) 461e1 464f VR PRIMARY CONTAINMENT LSTEEL .FIBERGLASSIO: RIGID PLASTIC U 90. NONE C1 99. OTHER (Specify) 464, VR SECONDARY CONTAINMENTIII I. STEEL Xk FIBERGLASS 13 10-RIGIDPLASTIC 0 90. NONE L1 99. OTHER (Specify) 4464b NT PIPING TRANSITION SUMP TYPE I. SINGLEWATI OUBLE WALL 90'. NONE 4MhJ 4641. SER PRIMARY CONTAINMENT .STEEL 4. FIBERGLASS 10. RIGID PLASTIC 90. NONE 99. OTHER (Specify) 464j SER SECONDARY CONTAINMENT .STEEL 4. FIBERGLASS I0.RIGIDPESTIC 90.NONE 99.OTHER(Speeify) 64'1 4Mk [FILLCOMPONENTS INSTALLED . SPILL BUCKET J. STRIKER PLATFJBOTTOM PROTECTOR 4. CONTAINMENT SUMP 4Mk1 4518-c M-P p, ' NSTRUCTIONTYPE 0 I. SINGLE WALL Q I DOUBLE WALL 0 3 NO DISPENSERS 0 90. NONE 46% CONSTRUCTION MATERIAL I. STEEL ❑ d. FIBERGLASS 0. RIGID PLASTIC 0 ??. OTHER S eci 469b -C V'i4�.A 8 . A: `. _. pp STEEL COMPONENT PROTECTION 0 2. SACRIFICIAL ANODES) 0 4. IMPRESSEDCURRENT a 6ISOLATION . 449. CERTIFICATION: I certify that thls UST system Is compatible with the hmrdous substance stored and that the Information provided herein Is true, accurate, and In full co Iisnce with legal requirements. APPLICANT SIGNATURE/ DATE 470. APPLICANT NAME (print) n1' APPLICANTT E 472_ A� L Qi (.t�i1 E �L. UPCF UST -11 -1/2 Rev. (12/2007)