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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK 111 <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One farm per UST) / <br /> TYPE OF ACTION /Check one item only. For a UST closure or removal,complete only this section and=ns 111.!1/,/V,and LY below) 430. <br /> ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION <br /> 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ONSITE ❑ 3.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: J30a DATE EXISTING UST DISCOVERED: 430b. <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only/ <br /> 1. <br /> BUSINESS <br /> E(Same as Facility Name or OBA-Doing Br¢iness AsJ 3 <br /> _S p�,Q,4,q,� <br /> BUSINESS SIT AQDRESS 103. CITY IOJ <br /> 0 0L r cp <br /> II. TANK DESCRIPTION <br /> TANK ID# d 432. TANK MANUFACTURER 433. t <br /> NK CONFIGURATION:THIS TANK IS 434. <br /> �� I.ASO F_UONE TANK Cmnplerc one page kr eachDATE UST SYS EM INSTALLED 435. 2.ONE IN A COMPARTMENTED UNIT comparonrniinNeunit <br /> TANK CAPACITY MGALLONS 436. MBER OF COMPARTMENTS IN THE UNIT 437. <br /> ` 15 00o Is <br /> III. TANK USE AND CONTENTS <br /> TANK USE Ia.MOTOR VEHICLE FUELING ❑ It MARINA FUELING ❑ 1c.AVIATION FUELING 439. <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Include UoeclOO ❑ 5.EMERGENCY GENERATOR FUEL[HSC§B±SLS(c)1 <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439. <br /> CONTENTS PETROLEUM: la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440. <br /> 7.DIESEL ❑ 5.IET FUEL ❑ 6.AVIATION GAS <br /> ._.. ______ ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440. <br /> _-___--.____ _._ <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ IO.ETHANOL ---------- <br /> ❑ 1 L OTHER NON-PETROLEUM(Specify): 4406 <br /> IV. TANK CONSTRUCTION <br /> _TYPE OF TANK 0",I SINGLE WALL 2_DOUBLE WALL ❑ 95.UNKNOWN 4q3 <br /> PRIMARY CONTAINMENT -- _ ...______.______.___..___ _._. <br /> ❑ 1.STEEL 3.FIBERGLASS ❑ 6.11111 <br /> BLADDER 44y. <br /> __� 7.STEEL+INTERNALLINING ❑ 95.UNKNOWN [1 99,OTH_ER(Specify): 4a4a <br /> SECONDARY CONTAINMENT - <br /> ❑ I.STEEL FIBERGLASS �� �7 JACKETED - -- 445. <br /> ❑ 90.NONE ❑ 6.EXTERIOR MEMBRANE LINER <br /> -- _�95.UNKNOWN _099,OTHER(Specify): 445a <br /> OVERFILL PREVENTION ❑ I.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT J.FILL TUBE SHUT-OFF VALVE JS±. <br /> ❑ 4.TANK MEETS RE UIREMENTS FOR EXEMPTION FROM OVERF L PREVENTION E UIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION __ L_S It- WALL ?DOUBLE WALL_ 0 99,OTHER __ __ ____ 460. <br /> SYSTEM TYPE I PRESSURE -.2_GRAVfIY 3.CONVENTIONAL SUCTION _❑ 4.SAFESUC_it0N[+3CCR q±636(aN3)I _ 458. <br /> PRIMARY CONTAINMENT ❑ LSTEEL �4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGIDPLASTIC 4W. <br /> _SI <br /> __❑ 90.NONE ❑ 95.U_NKNOWN__❑ 99.OTHER(Specify): 4648 <br /> SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 46.16. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify):_ Jyic, <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464a <br /> VI. VENT,VAPOR RECOVE Y(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT %I.STEEL ❑ 4.FIBERGLASS ❑ I0.RIGID PLASTIC ❑ 90.NONE 464e <br /> ___ ❑ 99.OTHER(Specify): 46101 <br /> VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 464E <br /> VR PRIMARY CONTAINMENT LSTEEL - a M, <br /> __ _ ❑ 4.FIBERGLASS ❑ l0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4Mcl, <br /> VR SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS_El 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): <br /> 461h. <br /> VENT PIPING TRANSITION SUMP TYPE ----------. 46461. <br /> ___.______ _ ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL �90.NONE 4 l <br /> RISER PRIMARY CONTAINMENT LSTEEL _. . <br /> 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): � �3' <br /> RISER SECONDARY CONTAINMENT 4MI <br /> ❑ ISTEEL 4.FIBERGLASS , ❑ 10.RIC(ID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464]. <br /> FILL COMPONENTS INSTALLED77F <br /> T 3.STRIKER PLATFJBOTTOM PROTECTOR 4Nk1. <br /> ❑ 4.CONTAINMENT SUMPDISPENSER CONTAINMENT(UDC) �CONSTRUCTION TYPE ___ L -❑ 2,DOUBLE WALL ❑ 3.NO DISPENSERS 90.NO, '�% <br /> CONSTRUCTION MATERIAL 1.SiEEl ------ - '""--- ---- 3s« -[yyy- <br /> ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) x 469c <br /> VIII. CORROSION PROTECTION ',r <br /> STEEL COMPONENT PROTECTION ❑ 2,SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448. <br /> IX. APPLICANT SIGNATURE _>' <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, <br /> accur a fiance with le al re irements. <br /> APPLICANT SIGNATUR DATE D O no. <br /> a r I <br /> APPLICANT NAME(print) B d� J71. <br /> I APPLICANT TITLE 472. <br /> UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org <br />