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wl-2010 UNIFIED PROGRAM CONSOLIDATED F,14 UNDERGROUND STORAGE TANK Pp OPERATING PERMIT APPLICATION-TANK INFORMATIO (o a form per 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 ❑ S.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430. DATE EXISTING UST DISCOVERED: 4306 L FACILITY INFORMATION FACILITY ID#(Agency Use Only) 17r- IA _ n _ 1 BUSINESS E(Same as FACI AME or DB - 'ng Business As) U 3 BUSINESS SITE ADD - I�, 103 CITY IN II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 ANI(CONFIGURATION: THIS TANK IS 434 A STAND-ALONE TANK L 4 2.ONE IN A COMPARTMENTED UNIT. - / l l C9 n. CfOttlCho. mLBl NnccuYV. DATE UST SYSTE LED 435 TANK CAP gt GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 M.TANK USE AND CONTENTS TANK USE ❑ Ia.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 [13.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(IucW UsM Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC g2$281.5(c)] ❑ 6.OTHERGENERATORFUEL [195.UNKNOWN .OTHER(Specify): 43% CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION G S '�� 7 ❑ 8.PETROLEUM BLEND FUEL .OTHER PETROLEUM (specify): � Ak-_ f/ Q) 41W NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4496 IV. TANK CONSTRUCTION TYPEOFTANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN a43 PRIMARY CONTAINMENT 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S ): 444. SECONDARY CONTAINMENT 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S(Specify) M5e 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 ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR g2636(e M 458 PRIMARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464e SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGFrURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 9,90.NONE 4644 VI.VENT,VAPORRECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PR04ARY CONTA24MENT 1.STEEL ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) a64e 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464f a64n VR PRIMARY CONTAINMENT 0 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4641 19 46411 VR SECONDARY CONTAINMENT 0 L STEEL ❑ 4.FIBERGLASS C3 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464h 4 Ih1 VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 464i. RISER PRIMARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC W90.NONE ❑ 99.OTHER(Specify) 4641 464'1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL El 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET 3.STRIKER PLAT'F/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 451.< VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS 90.NONE 469. CONSTRUCTION MATERIAL ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696 VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448_ M APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the harardous 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) 491' APPLICANTTITLE 473 UPCF UST-8-1/2 Rev.(12/2007)