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bo-� UNIFIED PROGRAM CONSOLIDATED F 1 UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UsI) TYPOF ACTION (Check one item only. For an UST permanent closure m removal,complete only this section and Sections L II,DI,IV,Rod IX below) W4436 01.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: 43a DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ _ / 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) fR 3 BUSg22,1 E 9.Y//M I-Uv KC �m Cl'I'Y SYCTG h-1��l io4 E.TANK DESCRIPTION TAYN/[�(m# p 432 TANK MANUFACTURER 433 T NKCONFlGURATION: THISTANKIS 434 1 Q OSO(' p O, ry/1�� `, 1.A STAND-ALONE TANK 'F TPJJ CV ❑2.ONE IN A COMPARTMENTED UNIT, DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436d0�e f°` in meu,Nt . O d NUMBER OF COMPARTMENTS IN THE UNIT a7 1 0'2 l III.TANK USE AND CONTENTS' TANK USE J&la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ le.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE Mduoa ua Dip ❑ 5.EMERGENCY GENERATOR FUEL[HSC 9252813M) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHM(S . ): 439e CONTENTS PETROLEUM: ❑ Ie.REGULAR UNLEADED ❑ la MIDGRADE UNLEADED M Ib.PREMIUM UNLEADED 440 ❑ 3.DIBSEL ❑ 5.]ET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLIND FUEL ❑ 9.OTHER PETROLEUM S 440e NON-PETROLEUM:❑ 7.USED OIL ❑ !0.ETHANOL 11.OTHER NON-PETROLEUMS 410b IV. TANK CONSTRUCTION - TYPEOFTANK ❑ I.SINGLE WALL 1&2.DOUBUWALL 095.UNKNOWN M3 PRIMARY CONTAINMENT 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ ].STEEL+INTERNALLINING ❑ 95.UNKNOWN ❑ 99.OTHER SECONDARY CONTAINMENT 002 I.STEEL .FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER ❑ 7.TICKETED 445 ❑ 90.NONE ❑ 95.[1NKNOWN ❑99.OTHER S ' ): M4 OVERFILL PREVENTION L AUDIBLE R VISUAL ALARMS 2.BALL FLOAT 3.FI,L TUBE SHUN-OFF VALVE 452 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED 52.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.G 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR 2636(,x3) 458 PRIMARY CONTAINMENT ❑ i.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Spxify): q6y SECONDARY CONTAINMENT ❑ L STEEL J&4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Spxify): 4640 PIPINGfrURBINE CONTAINMENT SUMP TYPE BI.SINGLEWALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL FIBERGLASS U 10.RIGID PLASTIC 0 9o.NONE 0 99.OTHER(Specify) abk 469 1 VENT SECONDARY CONTAINMENT I.STEEL El 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) a64r a64n VR PRIMARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90-NOME-0 99.0THER(Specify) 4649 VR SECONDARY CONTAINMENT4 L STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC PC 90.NONE El 99.OTHER(Spe.*) 464b 469h1 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 464L RISER PRIMARY CONTAINMENT .STEEL 4.FIBERGLASS LJ 10.RIGID PLASTIC ❑ 90.NONE LJ 99.OTHER(Specify) 464j RISER SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 461'1 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4641 1Nkl FILL COMPONENTS INSTALLED I.SPILL BUCKET 3.STRICER PLATE(BOTTOM PROTECTOR 4.CONTAINMENT SUMP 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469e CONSTRUCTION MATERIAL 1.STEEL ❑ 4.F ❑ 10.RIGID PLASTIC ❑ 99.UI H K(S uy) 469bc VIIL CORROSION,PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION Ms. 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 1a fug compliance wit al resquirements. APPLICANT SIGNATT'ar - DATE ^ 47R APPLICANT NAME(prin 971 APPLICANTTTTLE 4n. /if A I'c TK �dl erY OLY.rote/L UPCF UST-B-1/2 ( �`,Y� 2-2(12/2007)