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UNIFIED PROGRAM CONSOLIDATED FORM 1021 fJ q UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One fa p T) TYPE OF ACTION (Check one item only. For o UfT closure or removal,complete only this section and Sections L!/,I//./V,and[Xbelow) 4M ❑ 1.NEW PERMIT 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ONSITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: alas DATE EXISTING UST DISCOVERED: 4JW I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINNUSSame ao Name or DBA-Doing Business As) )_ BUSINEkS O'E/.r71 WDRE$S/. �U 103 1 CITY - W II. TANK DESCRIPTION 1 TANK ID It 431 MANUFACTURER 433_ TANK CONFIGURATION:THIS TANK IS 434. ' S �7 r�/ % �l ❑ I.ASTAN0.ALONE TANK Compiacompaµetmrsm QSn� / /amu /lWF i/K� (��ONEINACOMPARTMENTEDUNITcwnp wsin"'wit DATE UST SYSTEM INSTALLED a3s. iAw&CAPACITYIN_CjALLONS 436 NUMBER OF OMP E S IN THE UNIT 431, III. TANK USE AND CONTENTS TANK USE a.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(I Id UsW Oil) ❑ 5.EMERGENCY GENERATOR FUEL IHSC§2538L5(e)] ❑ 6.OTHER GENERATORFUEL ❑ 95.UNKNOWN ❑ W.OTHER(Specify): 439. CONTENTS PETROLEUM: ❑ Is.REGULAR UNLEADED ❑ Ic.MIDGRADEUNLEADED jkfb.PREMIUM UNLEADED 410. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 449a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 1 L OTHER NON-PETROLEUM(Specify): 4,106' IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT .STEEL ❑ 33 FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL ING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444,1 SECONDARY CONTAINMENT ❑ I.STEEL .FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 443. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 44k OVERFILL PREVENTION ❑ L AUDIBLE&VISUAL ALARMS .BALL FLOAT .FILL TUBE SHUT-OFF VALVE 451 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCV WASTE PIPING CONSTRUCTION PRIMARY CONTAINMENT ❑ L STEEL 9 .FIBERGLASS L ❑ 8.FLEXIBLE 46U. PIPING CONSTRUCTION - 0 L�SINGLE WALL_ _2 DOUBLE WALL _ ____ ._.__. .._._ - SYSTEMTYPE EPRESSURE _❑ 2.GRAVITY_ ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[3 CCR§±636(aN3)] 458. ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN C399.OTHER(Spe(Specify): 464. SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4606 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE EY1.SINGLE WALL EI 2.DOUBLE WALL [1 90.NONE 464d VI. VENT,VAPOR RECOVERY )AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 461cj. VENT SECONDARY CONTAINMENT ❑ 1.STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC .NONE ❑ 99.OTHER(Specify): 464[ a6 8. VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS [310.RIGID PLASTIC NONE ❑ 99.OTHER(Specify): 4 64M11l VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL .NONE 464` RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4. IBERGLASS ❑ 10 RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 'it: RISER SECONDARY CONTAINMENT ❑ L TEEL Or4.FIBERGLA - ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464k1 FILL COMPONENTS INSTALLED .SPILL BUCKET .STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 4514-c. VII. JINDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE [12.DOUBLE WALL._.._ 3.NO DISPENSERS El90.NONE 469. CONSTRUCTION MATERIAL &K.STEEL [14_FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) ,16vp VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448. IX. A ICANT SIGNATURE CERTIFICATION: I ce y a th(s U y is comp ibk iN the hazardous subannce stored and that the formation provided herein is [rue, aecu to i fu co ce with le 1 uirements. APPLICANT SIGNATUR DATE / 3 410" APPLICANT NAME(print) 471. APPLICANT TITL 472' UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org