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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,Ii,III,IV,and IX below) 930 1.NEW PERMIT [13.RENEWAL PERMIT [35.CHANGE OF INFORMATION El 6.TEMPORARY UST CLOSURE [17.UST PERMANENT CLOSURE ON SITE C] 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430. DATE EXISTING UST DISCOVERED: (I � O^ 4306 I. FACILITY INFORMATION FACB7TY ID#(Agency Use Only) I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business AS) 3 BUSINESS SITE ADDRESS 103CITY �..//. 1N 7,s �J W��- L I �t if.TANK DESCRIPTION TANK 11)# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 t'MS.A STAND-ALONE TANK ❑2.ONE M A COMPARTMENTED UNIT. / Co ae one a Eor each com mtin the udi. DATE UST SYSTEM INSTALLED 435 TANK CARACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 431 III.TANK USE AND CONTENTS TANK USE ❑ Ia.MOTORVEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING :39 Y13.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(mduda Uz OJ) ❑ 5.EMERGENCY GENERATOR FUEL(HSC ❑ &OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439. CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ It.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.]ET FUEL - - ❑ .AVIATIO"N ❑ S.PETROLEUM BLEND FUEL 9.OTHER PETROLEUM (S if): SaN� fa+n Or 44m NON-PETROLEUM:❑ 7.USED OIL ❑ l0.ETHANOL ❑ 11,OTHER NON-PETROLEUM(S ccify): 4406 IV.`.TANK CONSTRUCTION TYPE OF TANK i.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL,INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Sped ): 444. SECONDARY CONTAINMENT ❑ L STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.lACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445. OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 45'-. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION LSINGLE-WALLED ❑2.DOUBLE-WALLED [199.OTHER 460 SYSTENI TYPE ❑ L PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION f13 CCR§2636(.)(3)1 458 PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTR R(Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGfTURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND'RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 464R VR PRIMARY CONTAINMENT El L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 446 4 VR SECONDARY CONTAINMENT [I L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0-90-.NONE ❑ 99.OTHER(Specify) 4Mb 464hI VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464i. RISER PRIMARY CONTAINMENT ❑ LSTEn C] 4.FIBERGLASS ❑ IO.RIGID PLASTIC U 90.NONE ❑ 99.OTHER(Specify) 465 464'1 RISER SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE Ej 99.OTHER(Specify) 4641 464k1 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45). VII.UNDER DISPENSER'CONTAINMENT'(UDC) CONSTRUCTION TYPE ❑ 1,SINGLE WALL ❑ 2.DOUBLEWALL ❑ 3.NO DISPENSERS ❑ 90.NONE 4694 CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bs VIII. CORROSIONTROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.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 fail compliance with legal requirements. APPLICANT SIGNATURE DATE a10' APPLICANT NAME(print) 411, APPLICANT TITLE 4r. UPCF UST-B-112 Rev.(12/2007)