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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. For an UST permanent cloame or removal,complete only this section and Sections I,II,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: °J0i DATE EXISTING UST DISCOVERED: Gob I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) t BUSINESS NAME(Sameas FACILITY p[�.)��or DBA-Doing Business As) 3 J� SAY Y/GY - 7 (j Y) L ' BUSINESS SITE REjSrj IL TANK DESCRIPTION TANK 11)# C 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 ( O�� / �g0 Cb 51� ❑2.ONE A OMPARATMENTED UNIT. aeon 6aesch eam0a wric DATE US SYSTEM INSTALLED 435 TANK CAPACITY AL S NUMBER OF COMPARTMENTS IN THE UNIT 437 d 1. OCJO 2 III.TANK USE AND CONTENTS' TANK USE fila MOTOR VEHICLE FUELING ❑ Ib. RI MANA FUELING le.AVIATION FUELING 439 ❑ .CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Mu Uvea Up ❑ 5.EMERGENCY GENERATOR FUEL(HSC g232E13(c)j ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER Spai ): 43% CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Its.PREMIUM UNLEADED aaa T 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S i : 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 IV. TAW CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL EI 95.UNKNOWN 443 RgG aY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS 116.INTERNAL BLADDER 444 ❑ 7.STEEL, INTI MING ❑ 95.UNKNOWN ❑ 99.OTNER S 4Ma SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE 95.UNKNOWN ❑99.OTHER(S 445s OVERFILL PREVENT ION 1.AUDIBLE&VISUAL ALARMS U2.5ALLFWAT h 3.FILL TUBE SHAT-OFF VALVE 452, 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT I.WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑L SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE L PRESSURE ❑ 2.GRAVITY 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR 42636(a)(3)] 359 PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specily): 46M SECONDARY CONTAINMENT ❑ L STEEL4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 964c PIPING/TURBINE CONTAINMENT SUMP TYPE I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464a VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL.PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 1.STEEL IR 4.FIBERGLASS 11 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464e 46k1 VENT SECONDARY CONTAINMENT0 L STEEL IA 4.FIBERGLASS E3 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 4Nf 4Mf3 VR PRIMARY CONTAINMENT0 I.STEEL [A 4.FIBERGLASS C 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 464g 464 1 VR SECONDARY CONTAINMENT1.STEEL 4.FIBERGLASS I0.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4Nh 46M1 VENT PIPING TRANSITION SUMP TYPE in 1.SINGLE WALL 2.DOUBLE WALL 1&90.NONE WL RISER PRIMARY CONTAINMENT 1.STEEL Ll 4.FIBERGLASS U 10.RIGH)PLASTIC U 90.NONE U W.OTHER(Spoefy) 464j 461'1 RISER SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGH)PLASTIC 90.NONE 99.OTHER(Specify) 461k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 0 3.STRIKER PLATEWTTOM PROTECTOR q 4.CONTAINMENT SUMP 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPEL SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS [190.NONE 46A CONSTRUCTION MATERIAL I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bc CORROSION PROTECTION j STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑4.IMPRESSED CURRENT 50 6.ISOLATION 44a. IR. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is truq accurate, and in full compliance with legal requirements. APPLICANT SIGNATURE , DATEf-,g L J/ 2 _ aro. o- �a APPLICANT NAME(print) 471' APPLICANT TITLE I'y °n. Nf}S ' n-/ RJiJ UPCF UST-B-1/2 Rev.(122007)