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7'�52 aa I ,,.WNIFIED PROGRAM CONSOLIDATED Fi%.A ►U2 k /a UNDERGROUND STORAGE TANK - LI OPERATING PERMIT APPLICATION-TANK INFORMATIO (One fod iL)U T) E OF ACTION (Check one item only. For an UST pemlanent closure or removal,complete only this section and Sections I,11,III,IV,and IX below) 430 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430. DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as F MLI Y NAME or A-Do" g Business As) ^L 3 BUSINESS SITE ADDRESS n\✓�a3�/Cc.h , 1� /1) . ) L71 TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK 1S 434 lASTAND-ALONE TANK v 499 l „ & in 2.ONE IN A COMPARTMENTED UNIT. Co ktc ovs for wdi com ermt rola uah. DATE UST SYf TALLED 435 TANKTY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 M.TANK USE AND CONTENTS TANK USE 0 1a.MOTOR VEHICLEFUELING ❑ Ib.MARINA FUELING 0 lc.AVIATION FUELING 439 0 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(b Il Used Oil) ❑ S.EMERGENCY GENERATOR FUEL[NSC§252815(c)j 0 6.OTHERGENERATOR FUEL ❑ 95.UNKNOWN .OTHER (Specify): 43% CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ III.MIDGRADE UNLEADED 0 Ih.PREMIUM UNLEADED 440 ❑ 3.DIESEL 0 5.JET FUEL 0 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL 9.OTF3FR PETROLEUM (Specify): S i ): to 440. NON-PETROLEUM:0 7.USED OIL 10.ETHANOL ❑ 11.OTHER NON-PETROLEUMS i ): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL 2.DOABLE WALL O 95.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 0 7.STEEL t INTERNAL LINING ❑ 95.UNKNOWN 0 99.OTHER (specify): aa4e SECONDARY CONTAINMENT 1.STEEL [13.FIBERGLASS 0 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED as 90.NONE 0 95.UNKNOWN 0 99.OTHER(Specify) 445. OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452, 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 1.SINGLE-WALLED ❑2.DOUBLE-WALLED 0 99.OTHER 460 SYSTEM TYPE1.PRESSURE [12.GRAVITY 0 3.CONVENTIONAL SUCTION 0 4.SAFE SUCTION(23 CCR§2636uoD)1 458 PRIMARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE 0 95.UNKNOWN ❑ 99.OTHER(s ci ): 464. SECONDARY CONTAINMENT ❑ L STEEL 0 4.FIBERGLASS ❑ 8.FLEXIBLE 0 10.RIGID PLASTIC 4646 90.NONE 0 95.UNKNOWN ❑ 99.OTHER(Specify): a6ac PIPINGMJRBLNE CONTAINMENT SUMP TYPE 0 1.SINGLE WALL 0 2.DOABLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 464c 464e1 VEIN SECONDARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC O.NONE 99.OTHER(Specify) 464f 464h VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464g d64 I VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 099.OTHER(Specify) 464E 464h1 VENT PIPING TRANSITION SUMP TYPE O 1.SINGLE WALL O 2.DOUBLE WALL W90.NONE 464i. RISER PRIMARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC >J�90.NONE U 99.OTHER(Specify) 461j ,Imp RISER SECONDARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC fg'90.NONE 0 99.OTHER(Specify) 464k 4 Ikl FILL COMPONENTS INSTALLED 0 1.SPILL BUCKET 0 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SOW 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 0 1.SINGLE WAIL 0 2.DOUBLE WALL ❑ 3.NO DISPENSERS 90.NONE 469a CONSTRUCTION MATERIAL 0 1.STEEL 0 4.FIBERGLASS 0 IO.RIGID PLASTIC 0 99.OTHER(Specify) 4696c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION 0 2.SACRIFICIAL ANODE(S) 0 4.IMPRESSED CURRENT 0 6.ISOLATION 448. 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 legal requirements. APPLICANT SIGNATURE DATE 470, APPLICANT NAME(print) 411 1 APPLICANT TITLE 472- UPCF UST-B-1/2 Rev(12/2067)