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2322 UNIFIED PROGRAM CONSOLIDATED FSM // UNDERGROUND STORAGE TANK j� OPERATING PERMIT APPLICATION-TANK INFORMATION( form P. 31)t , ( TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1.11,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: 43% I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ U U 1I A I _ -7 2 ^ 1 BUSINESS E( me as FA NAME or DBA- in us' ass BUSINESS SITE AD SS nl r(O AD 103 CITY ioa QC1�gV III./TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 1 TANK CONFIGURATION: THISTANKIS 434 11_�/ ,Z 1.A STAND-ALONE TANK 8 (Z2SS�VV Ili'` ❑2.ONE M A COMPARTMENTED UNIT. -Co Ida are mefor each mm in dmwe. DATE U INSTALLED 435 TAMC CqtV.IN GALLONS 436 1 NUMBER OF COMPARTMENTS IN THE UNIT 433 M.TANK USE AND CONTENTS TANK USE ❑ Ia.MOTOR VEHICLE FUELING 0 Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 0 3.CHEMICAL PRODUCT STORAGE IiLn.HAZARDOUS WASTE(nch Uxd GJ) ❑ 5.EMERGENCY GENERATOR FUEL[xsC§252815(c)I 0 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN 0 99.OTHER (Specify): 439. CONTENTS PETROLEUM: 0 Is.REGULAR UNLEADED 0 Ic.MIDGRADE UNLEADED ❑ 1 b.PREMIUM UNLEADED 440 0 3.DIESEL ❑ 5.JET FUEL 0 6.AVIATION GAS 0 8.PETROLEUM BLEND FUEL 0 %OTHER PETROLEUM (Specify): ma NON-PETROLEUM 7.USED OIL ❑ 10.ETHANOL 0 11.OTHER NON-PETROLEUM(Specify): 44ob IV. TANK CONSTRUCTION TYPEOFTANK 1.SINGLEWALL A 2.13OUBLEWALL 095.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL 0 3.FIBERGLASS 0 6.INTERNAL BLADDER 444 0 7.STEEL,INTERNAL LINING 0 95.UNKNOWN 0 99.OTHER (S ify): 444. SECONDARY CONTAINMENT )$ L STEEL 0 3.FIBERGLASS 0 6.EXTERIOR MEMBRANE LINER 0 7.JACKETED 445 0 90.NONE 0 95.UNKNOWN 0 99.OTHER( i ): *15.OVERFILL PREVENTION .AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 0 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 0 2.DOUBLE-WALLED [199.OTHER Oso SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY 0 3.CONVENTIONAL SUCTION 0 4.SAFE SUCTION(23 CCR§2636(.X3)) 458 PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS 0 8.FLEXIBLE 0 10.RIGIDPLASTIC 4N 0 90.NONE 0 95.UNKNOWN 0 99.OTIHIR(Specify): 41Aa SECONDARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS 0 8.FLEXIBLE 0 10.RIGID PLASTIC 464b 90.NONE 0 95.UNKNOWN 0 99.OTHER(S i ): awc PIPING/TURBINE CONTAINMENTUMP TYPE 0 1.SINGLE WALL ❑ 2.DOUBLE WALL 0 90.NONE Abad VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PEPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENTI.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE Q 99.OTHER(Specify) 464c 464,1 VENT SECONDARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC90.NONE 0 99.OTHER(Specify) 4wf 1>4 awn VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.TOTHER(Specify) 4648 46491 VR SECONDARY CONTAINMENT 0 L STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC e90.NONE D 99.OTHER(Specify) 4wh 464h1 VENT PIPING TRANSITION SUMP TYPE 0 1.SINGLE WALL 0 2.DOUBLE WALL JF90.NONE WL RISER PRIMARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS 0 10.RIGIDPLASTIC 90.NONE 0 99.OTHER(Specify) 464) 464'1 RISER SECONDARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC90.NONE 0 99.OTHER(Specify) 4wk 464k1 FILL COMPONENTS INSTALLED 0 1.SPILL BUCKET 0 3.STRIKER PLATE/BOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 0 1.SINGLE WALL 0 2.DOUBLE WALL 0 3.NO DISPENSERS .NONE 469a CONSTRUCTION MATERIAL 0 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 99.OTHER(Specify) a696s VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION 0 2.SACRIFICIAL ANODES) O 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) ... I APPLICAFIT TITLE 4r2. UPCF UST-B-1/2 Rev.(12!2007)