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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION -TANK INFORMATION tone tore"per(IST' TYPE OF ACTION (Ckxk one near nnh p'n"a Uv closure or cnnovol.canple(e oalr dos section and Sec/ions L H.I(/.Il:ald LY bear) '10 ❑ i.NEW PERMIT 3. RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 0 7.UST PERMANENT CLOSURE ON SITE ,F1 .UST REMOynt. DATE UST PERMANENTLY CLOSED: '30+ DATE EXISTING UST SCOVERED 'lob I. FACILITY INFORMATION I. FACILITY ID k I Agrucv Use Onhq - BUSINESS�lsL ?te ass�F�In'AAMW,or�.1-Doing&rsiaess ds) -_ s BUSINESS SITE DDRESS •ice �L 103 CITY e , la r 2�0 ZUAJ I _ S 11. TANK DESCRIPTION TANK ID k "'- ANK MANUFACTURER 00 TANK CONFIGURATION:THIS TANK IS .`r 44 Seo / . ❑ L STAND-ALONE TANK Ca pae we pp lm exa •f�'WG _ONE INA COMPARTMENTED UNIT DATE UST SY,Th�,��,iTALLED J15 TANK OPACITY M G*L 5 'M NUMBER OFSOt�1PAR� TS�ILN St UNIT USE AND CONTENTS (�f TANK(ISE SK..MOTOR VEHICLE FUELING ❑ Ib.MARINA FLIELIN40 ❑ I. AVIATION FUELING �N ❑ 3.CHEMICAL PRODUCT STORAGE 0 e.HAZARDOUS WASTE(LduOw Una aO ❑ ;.EMERGENCY GENERATOR FUEL[HSC g252818111 ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN99.OTHER(Spedfy): O9. .LFII-_ -- M6 CONTENTS PETROLEUM: ❑ 31..DIESEL UNLEADED 0 S.JET FUEL UNLEADED 6AVI TIN UNLEADED 0 I.DIESEL ❑ S.JET NEL ❑ 6 AVIATION GAS ❑ S.PETROLEUM BLEND FUEL L] 9.OTHER PETROLEUM(Spttif�:_ NON-PETROLEUM:❑ 7.USED OIL 10.ETHANOL 0 I1.OTHER NON.PETROLEUM(S i : M0Y' IV ANK CONSTRUCTION TYPE OF TANKC3 IG_LE WALL 2.DOUBLE WALL [3 95.UNKNOWN ILII__ NS' PRIMARY CONTAINMENT .STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER _ _Q 7.STEEL,INTERNALE G _ [3 95.UNKNOWN ❑ 99.OTHER(Sp«iryt _4!!• SECONDARY CONTAINMENT If I.STEEL .FISERGIaSS ❑ 6.EXTERIOR MEMBRANE LINER 0 7.JACKETED H5. ❑ 90.NONE __0 95.UNKNOWN /[]99.OTHER(Spam M5. - �r OVERFILL PREVENTION O I.AUDIBLE&VISVALALARMS 2.SALLFLOAT 3.FILL TUBE SHUT-OFF VALVE 352 e.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCTW WASTE PIPING CONSTRUCTION PIPING CONSTRUC770N 1 GLE WALL 2.DOUBLE WALL E_99.OTHER td0 SYSTEM TYPE LPRESSUBE 2 VITY _ ❑ 3.CONVENTIONAL SUCTION ❑ e.SAFE SUCTION f23 CCR 326561.X5)1 _(x PRIMARY CONTAINMENT Q 1.STEEL FIBS GLASS O f.FLEXIBLE ❑ 10.RIGID PLASTIC _ 090 NONE_ 0 95 KNOWN ❑ 99.OTNER(Specify): c61t ___ SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ &FLEXIBLE 0 t0.RIGID PLASTIC wt6 ❑ 90.NONE _ C1 9 KNOWN O ".OTHER(Specibo PIPING/TURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL E3 90.NONE 'b'a V1. VENT,VAPOR RECOVERY )AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT E3 L STEEL t.FIBERGLASS ❑ 10.RIGID PLASTIC 0 W.NONE ❑ 99.OTHER ISpx'fy): rNei. VENT SECONDARY CONTAINMENT L] ).STEEL ❑ e. ERGLASS ❑ to.RIGID PLASTIC .NONE ❑ 99.OTHER(SpeciJO: +an VR PRIMARY CONTAINMENT 0 1.STEEL 6.FIBERGLASS ❑ 10.RIGID PLASTIC -❑ 9s00NONE 0 99.OTHER(Spe iAIW._`- a VR SECONDARY CONTAINMENT ❑ I.STEEL ❑ e.FIBERGLASS L] 10,RIGID PLASTIC NE ❑ 99.OTHER VENT PIPING TRANSITION SUMP TYPE (] I.SINGLE WALL ❑ 2.DOUBLE WALL. .NONE -- ___ -_.._-._ RISER PRIMARY CONTAINMEM 1.S'f£EL ❑ s.F ERGLASS ❑ 10.RIGID PLASTY 0 W.NONE ❑ 99.OTHER(Specify.�:__ �, RISER SECONDARY CONTAINMENT D 1_-STEEL 994.FIBERGLA ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.0'f HER(Sp Ify): t _tbYl. FILL COMPONENTS INSTALLED 1.SPILL BUCKET .STRIKER PLATEIBOTTOM PROTECTOR �.fONTA1NMENT SUMP c ep _ _ _ _. VII. ER DISPENSER CONTAINMEN`f'(UDC) _ CONSTRUCTION TYPE IPIGLE WAIL ❑ 2.DOUBLE WALL 3.NO DISPENSERS L ❑ 50.NONE -URp CONSTRUCTION MATERIAL STEEL C36.FIBERGLASS [3t0.RIGID PLASTIC ❑ 99.OTHER(Specify) _ opts VIII. CORROSION PROTECTION STEELCOMPONEECTION ❑ 2.SACRIFICIAL ANODE(S) 06.IMPRESSED CURRENT 06.15 ELATION .gym 19 IX A LICANT SIGNATURE CERTIFICATION: bat this IJ em it corn tib with the hetardom Subsance Stored ant the Infee m.tbp proridrd i~�.,,_„b true. t Jet .0 n full he.wIM i ulrement. ® em APPLICANT SIGN DATE I 411APPLICANT TITLE NT APPLICANAME(poop / M __ .. p off ILII t. UPCF USF-B Rev.(12/2007)- 1/2 www.anidocs.org