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UNIFIED PROGRAM CONSOLIDATED FORM ! / UNDERGROUND STORAGE TANK O f 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 I=and Sections I,11,111,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: 431 DATE EXISTING UST DISCOVERED: 430h FACILITY]D#(Agency Use Only) L FACILITY INFORMATION_ I BUSINESS NAME(Saone as FACILITY NAME or DBA-Doing Business As) 3 BUSINESS SITE ADDRESS 103 CITY 104 5T&c II.TANK DESCRIPTION TANK 11)# 432 TANK MANUFACTURER 433 T CONFIGURATION:TRIS TANK IS 434 1 A N-o 4 910 2- �/1 F,��fi A STAND-ALONE TANK r 6C V V [12.ONE IN A COMPARTMENTED UNIT. DATE UST YSTE TALLED 435 coffmiete 0M PW bar cac]com in the wk d Z TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS fN THE UNIT 437 10. 00 III.TANK USE AND CONTENTS TANK USE (,la.MOTOR VEHICLE FUELING ❑ I b.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Indww Used oip ❑ 5.EMERGENCY GENERATOR FUEL(HSC 125281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 �3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ &.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (S 940a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ I I.OT74ER NDN-PETROLEUMS 4406 IV. -TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN t43 PRIMARY CONTAINMENT 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S c' ): 444a SECONDARY CONTAINMENT ❑ !.STEEL 3.FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER ❑ T.IACKETED 445 ❑ 90.NONE 95.UNKNOWN ❑99.017HER(S ' ): 445a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT IS,3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTTER 460 SYSTEM TYPE [+�1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(aX3)1 456 PRIMARY CONTAINMENT ❑ 1.STEEL M 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ ]0.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Speeify): 464& SECONDARY CONTAINMENT ❑ L STEEL RL 4.FIBERGLASS ❑ B.FLEXIBLE ❑ IO.RIGID PLASTIC 4&74 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99,OTHER(Specify): 464c PIP1N&T.mINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 40.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 10.RIGID PLASTIC �.-4 ❑ 40.NONE ❑ 99.OTHER(Specify) 464e VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS 464e1 ❑ 10.RIGID PLASTIC 0.NONE ❑ 99.OTHER(Specify} 464f VR PRIMARY CONTAINMENT4648 ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464g VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NOISE ❑ 99.OTHER(Specify} 4464] VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL 44641 �, -1 [� 2.DOUBLE WALL 0.NONE 64h1 RISER PRIMARY CONTAINMENT may.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464] RISER SECONDARY CONTAINMENT 1.STEEL 464 I ❑ 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE D 99.OTHER(Specify) 464k FILL COMPONENTS INSTALLED464k1 I.SPILL BUCKET .STRIKER PLATE/BOTTOM PROT£CTOR ❑ 4.CONTAINMENT SUMP 451a-c VII.UNDER DISPENSER CONTAIN'NffiNT.(UDC) CONSTRUCTION TYPE Q�.1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS _ ❑ 90.NONE 459a CONSTRUCTION MATERIAL L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify} 469bc VIIL CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 44&. 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 with legal requirements. APPLICANT SIGNATURE. DATE l-- f" 4 �� ;. 470. APPLICANT NAME(print) 471. APPLICANT TITLE 471. r l sir'_y N 4(/Ye P OtL147 ep,,- UPCF UST-B-1/2 Rev.(12/2007)