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• • T UNIFIED PROGRAM CONSOLIDATED FORM Oe/ UNDERGROUND STORAGE TANK hIV jf OPERATING PERMIT APPLICATION-TANK INFORMATION(One fo m pe UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,II,III,IV,and IX below) 430 19 I.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: 410a I DATE EXISTING UST DISCOVERED: 4301, I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 L BUS SS SITE ADD Lin I CITY IN II.TANK DESCRIPTION TAMC ID# 432 TANK MANUFACTURER ... CONFIGURATION:CONFIGURATION: THIS TANK 1$ 434 .A STAND-ALONE TANK S ❑2.ONE INA COM PARTMENmED UNIT. Com de one Mef nch wmlaaanmtin lM1e amL DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 III.TANK USE AND CONTENT 'Zinn oSF ❑ 1a.NIOTORVEHICLEFUFLING ❑ io NIARINAFUELING ❑ Ic..AVLATION FUELING 439 ` 'J.CHEMICAL PRODUCT STORAGE ❑ 4.14AZARDOUS WASTE(lndWdv Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC M281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 43% CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL -- ❑ 6.AVIATION GAS --- ❑ 8.PETROLEUM BLEND FUEL IjD.OTHER PETROLEUM (Sis.ifft 44aa NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11,OTHER NON-PETROLEUM(Specify); 44ab IV. TANK CONSTRUCTION- TYPE OF TANK SINGLE WALL E] 2.DOUBLE WALL ❑ 95.UNKNOWN 4a3 PRIMARY CONTAINMENT ❑ I.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S eci ): a44a SECONDARY CONTAINMENT ❑ L STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.IACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION Cl 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT 0 3.FILLTUSESHUT-OFFVALVE 452. Cl 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION -1.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ❑ L PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(0(3)1 458 PRIMARY CON'TAINMEN'T ❑ I.STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.1IGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4611 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464. 464'1 VEIN SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC [1-90.NONE ❑ 99.0 THER(Specify) 4Rf 4Mn VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4646 46 1 VR SECONDARY CONTANNIENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4Mh 46 h1 VENT PIPING TRANSITION SUMP TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 461i. RISER PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 4641 RISER SECONDARY CONTAINMENT ❑ LSTEEL ❑ 4.FIBERGLASS 10.RIGIDPLASTIC 90.NONE ❑ 99.OTHER(Sp.Hy) 146� FILL COMPONENTS INSTALLED ❑ LSPILLBUCKET 3.STRIKERPLATFJBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP VII.UNDER DISPENSER CONTAINMENT(UDC) CON.'STRUCTION TYPE ❑ L SINGLE WALL o nnnu,v WALL❑ _..... ...... ❑ 3.NODISPENSERS ❑ 90.NONECONSTRUCTION MATERIAL ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) VIIL CORROSION PROTECTION STEEL COMPONENTPROTECTION ❑ 2.SACRIFICL'.L:'.N0DE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 7a LN 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 SIGNATUREDATE 430" APPLICANT NAME(print) 471" APPLICANTTITLE 41,' UPCF UST-B-112 Rev.(12/2007)