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sa UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK ! 19 M14 OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) a3a WPE OF ACTION (Check one item only. Foran UST permanent closure or removal,complete only this section and Sections I, NTAL ® 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF ❑ 6.TEMPORARY UST CLOSURE [17.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL LTH D 43ob � DATE Uh ST PERMANENTLY CLOSED: DATE EXISTING UST DISCOVERED: J I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) b G U 6 Q S BUSINESS NAME(Same as FACILITY NAME mDBA-DoingOBusinSss A;) /✓� on r s� BUSINEs ADDESn ,UE/t 12 A 0J crrY YO II.TANK DESCRIPTION 11T TANK 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 34 N v o ,U 1 t l� T/C✓�( O A STAND-ALONE TANK T!1 V a U 2.ONE IN A COMPARTMENTED UNIT. 4 Com letc one afor each coin enmmt in the unit. DATE UST YS M TALLER 436 NUMBER OF COMPARTME S THE UNIT 431 C T _ a3s TANK /�CII'Y-1N GhI.I.ONS �v J Z lj L ICn..fJTAANKCUUSSELAND CONTENTS TANK USE 15,41. .CHEMICAL PROD FUELING ❑ 4.HAZARD FUELING ❑ 5.EMERGENCY FUELING 39 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(includes Used Oil) ❑ S.EMERGENCY GENERATOR FUEL[HSC g25281.5(c)] 39e ❑ 6.OTHER GENERATOR FUEL [1a 95.UNKNOWN ❑ 99.OTHER(Specify): 3% CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ie.MIDGRADE UNLEADED ❑ 1b.PREMrUJM UNLEADED -t"� DIFCFI El 5.SET FUEL [16.AVIATION GAS 4� I B.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S i : NON-PETROLEUM:❑ 7.USED OIL [110.ETHANOL Wb ❑ II.OTHER NON-PETROLEUMS i V. TANK CONSTRUCTION TYPE OF TANK ❑ I SINGIS?WALL .DOUBLE WALL ❑ 95.UNKNOWN 143 PRIMARY CONTAR MENT .STEEL 3.FIBERGLASS ❑ 6.INT-P12NAL BLADDER 444 ❑ 7.STEEL+INTEtNALLRdING ❑ 95.UNKNOWN ❑ 99.OTHER S i 444° SECONDARYCONTAINMENT ❑ 1.STEEL ERGLASS ❑ 6.EXTERIORMEMBRANELWER ❑ 7.IACKETED as ❑ 90.NONE 95.UNKNOWN ❑99.OTHER S eci N5a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALAAMB 2.BALL FLOAT .FRS.TUBE SHUTOFF VALVE 152. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFR PREVENTION EQUIPMENT V. PRODU /WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION " 01 GLE-WALLED 2.DOUBL&WALLED ❑99.OTHER 166 SYSTEMTYPE Rr.PRESSURE ❑ 2 RAVITY ❑ 3.CONVENTIONALSUCTION ❑ 4.SAFE SUCTION[13CCRg2636(eX31 458 PRIMARY CONTAINMENT ❑ 1.S"FEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 9 1114ICNOWN ❑ 99.OTHERS ecify): 464e SECONDARY CONTAINMENT El1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 1646 ❑ 90.NONE ❑ OWN [399.OTHER(Specify): 464c PIPmrruRBINE CONTAINMENT SUMP TYPE R 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 46Cd VI.VENT,VAPOR RECOVE (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1 STEEL 4.FIBERGLASS ❑ 10.KIGID PLASTIC ❑ 90 NONE ❑ 99.OTHER(Specify) 464e 464el FFILL SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4 FIBERGLASS ❑ 10.RIGID PLASTIC 90�NONE ❑ 99.OTHER(Specify) 464f 466,3 IMARY CONTAINMENT L STEEL 4.FIBERGLASS IO.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4646 4 I CONDARY CONTAINMENT 1.STEEL 4.F16ERGLASS I0.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 46ah dbahl PIPING TRANSITION SUMP TYPE INGLE WALL 2.DOUBLE WALL .NONE 4611. PRIMARY CONTAINMENT 1„STEEL �3HERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464i 46'1 SECONDARY CONTAINMENT ❑ 1. EL p 4.FIDERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 41. COMPONENTS INSTALLED 1.SPILL BUCKET ❑ 3.STRIKER PLATEBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451ec VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE INGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469. CONSTRUCTION MATERIAL. 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b< VIII.. CORROSION PROTECTION STEEL COMPONENT PROTECTION [12.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 44s' 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 cam Hance with legal r$quirements. d]0. APPL T SIGNATURE DATE a 21 APPLICANT NAME(print) 411' APPLICANT TITLE 472. bdn ��v S • Gli/1S e,G aavN�i1 leI22 UPCF UST-B-112 Rev.(1212007)