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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,11,III,IV,and D{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: 43oa DATE EXISTING UST DISCOVERED: 430b L FACILITY INFORMATION FACILITY ID#(Agency Use 0r4fY) I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 -/t N2HA 1t 4Ei BUSINESS S E AWRESS 103 CITY 5 ft 104 II.TANK DESCRIPTION TANK 113# 432 TANK MANUFACTURER 433 T NK CONFIGURATION:THIS TANK IS 434 TA Qro lf ��C 0 1..A STAND-ALONE TANK TPJ:J ❑2.ONE IN A COMPARTMENTED UNIT. Canl�ft ora pw for each mmpotnem in the unit _ DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 d L1 L7 C) 1 � III.TANK USE AND CONTENTS TANK,USE f5.la.MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ !c.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(]ndudes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§2$281.5(c)I ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 0Q.OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM fS 440a NON-PETROLEUM;❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUMS A4Dh IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 1&2.DOUBLE WALL [195.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL [33.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 C17.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S ): 444a SECONDARY CONTAINMENT ❑ L STEEL 1U.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER{$ ); 4451 OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEET$REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT]WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑I.SINGLE-WALLED 192.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑4.SAFE SUCTION[23 CCR§2636(aK3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL4.FIBERGLASS ❑ 8.FLEXIBLE LJ10.RIGID PLASTIC 464 E] 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL -K 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c EVENT TURBINE CONTAINMENT SUMP TYPE L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING:CONSTRUCTTON RIMARY CONTAINMENT 0 1.STEEL FIBERGLASS ❑ 10.RIGID PLASTIC ❑90.NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ I0.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464f 464fl VR PRIMARY CONTAINMENT Cl 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ".OTHER(Specify) 464g 464 1 VR SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ ]0.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464h VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL [12.DOUBLE WALL 0 90. 464h1 NONE 464L RISER PRIMARY CONTAINMENT J&J.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464j RISER SECONDARY CONTAINMENT ❑ ],STEEL U 4.F03ERGLASSi'K464'1 ]0.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATEBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la•c VII.UNDER DISPENSER CONTAINMENT.(UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469. CONSTRUCTION MATERIAL 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIG®PLASTIC ❑ 99.OTHER(Spccify) 469b� VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ C IMPRESSED CURRENT 6.ISOLATION 448. 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 compliance witbjegal requirements. APPLICANT SIGNAT7 TD' - DATE 470. APPLICANT NAME(prin 471. APPLICANT TITLE i 471_. UPCF UST-ll-1/2 Rev.(12/2007)