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l ILULIft IFIED PROGRAM CONSOLIDATED FOYAMARX 6 2��5 UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION TSCPE OF ACTION (Check one item only. Foran UST permanent closure or removal, complete only this section and Sections I, II, 0 (� 1. NEW PERMIT (] 3. RENEWAL PERMIT ❑ S. CHANGE OF INFO - T+1tcal'r Q 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE . UST REMOVAL DATE UST PERMANENTLY CLOSED: "a DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) I BUS SS NAME (Same es FACILITY NAME or DBA -Doing Business As) 3 ivy 9 vac ST s �.1 BUSINESS SITE ADDRESS N� 193 cITY� oC �L✓ as II. TANK DESCRIPTION TANK ID # 412 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 6 A STAND-ALONE TANK W !V> [12. ONE IN A COMPARTMENTED UNIT. Com Into om for recti cum art tin a,e unit DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 M. TANK USE AND CONTENTS TANK USE ❑ Is. MOTOR VEHICLE FUELING ❑ Ib. MARINA FUELING ❑ In. AVIATION FUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE &r-4. HAZARDOUS WASTE Oncludecuad O'd) ❑ 5. EMERGENCY GENERATOR FUEL [HSC §2s2sL5(.)l . ❑ 6.OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439. CONTENTS PETROLEUM: ❑ Ia. REGULAR UNLEADED ❑ In. MIDGRADE UNLEADED ❑ Ib. PREMIUM UNLEADED 440 ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS - ❑ S. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM S ify): ys'ga o/ 44994 NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ❑ 11. OTHER NON -PETROLEUMS pt ggpb IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL J9 2. DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1. STEEL aff 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 ❑ 7. STEEL+ INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER S ' 44N SECONDARY CONTAINMENT ❑ 1. STEEL c♦43.3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 445a OVERFILL PREVENTION . AUDIBLE & VISUAL ALARMS C6,e2.BALLFLOAT . FILL TUBE SHUT-OFF VALVE 452. ❑ 4. TANK MEETS REQUIREMENTS FOR ON FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT / WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1. SINGLE -WALLED J22. DOUBLE -WALLED ❑ 99. OTHER 4sa SYSTEM TYPE ❑ 1. PRESSURE 2. GRAVITY El 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION lz; CCR §2636(4)(3)) 458 - PRIMARY CONTAINMENT ❑ 1. STEEL 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGIDPLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER(S ify): 4644 SECONDARY CONTAINMENT ❑ I. STEEL @r4I FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464b ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER S ify): 4640 PIPINGITURBINE CONTAINMENT SUMP TYPE ❑ 1. SINGLE WALL . DOUBLE WALL ❑ 90. NONE 4644 VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 1. STEEL TFIBERGLASS ❑ 10. RIGID PLASTIC 0 90. NONE ❑ 99. OTHER (Specify) 464n 464et VENT SECONDARY CONTAINMENT ❑ 1. STEEL K 4. FIBERGLASS ❑ 10. RIGIDPLASTIC ❑ 90. NONE 0 99. OTHER (Specify) 464r 464f1 VR PREMARY CONTAINMENT 1. STEEL 4. FIBERGLASS 10. RIGIDPLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464g 464 1 VR SECONDARY CONTAINMENTy ❑ 1. STEEL ❑ 4. FIBERGLASS 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) a6an 464h1 VENT PIING TRANSITION SUMP TYPE D 1. SINGLE WALL lir,2.DOUBLE WALL Cl 90. NONE RISER PRIMARY CONTAINMENT 2�1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE99.OTTM (Specify) 464j 469'1 RISER SECONDARY CONTAINMENT I. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464k 464kI FILL COMPONENTS INSTALLED 1. SPILL BUCKET _Z 3. STRIKER PLATE/BOTTOM PROTECTOR ❑ 4. CONTAINMENT SUMP 451st VII- UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE❑ 1. SINGLE WALL 032. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 469. CONSTRUCTION MATERIAL 'ic/ ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGIDPLASTIC ❑ 99. OTHERS m9bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION f Ms. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate, and in full compliance with lead requirements- e uirementsAPPLICANT APPLICANTSIGNATURE 41Z1 / _ 4M - O APPLICANTNAME(print)471' „/ APPLICANT TITLE 4n. t'C�y Q Vx UPCF UST -B-12 a f - Rev. !12214171