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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One torn per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,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 El 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 410a FDATE EXISTING UST DISCOVERED: 4396 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) r /1 _ D _ j O 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As)A /M// sm 1 BUSINESS SITE ADDRESS 103CITY 104 s 141 Sf_Mrl V - ._ch 3" H.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 411 TANK CONFIGURATION: THIS TANK IS 434 /n w&t). (� �1.A STAND-ALONE TANK V V�T/r lS l.U' t� 2.ONE IN A COMPARTMENTED UNIT. Comvlmopo rr ah mm mum mal. DATE S M INSTALLED 435 TANK CAPACITY M GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 III.TANK USE AND CONTENTS TANK USE Is.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ le.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE U mh USW Oi0 ❑ 5.EMERGENCY GENERATOR FUEL MSC§2518LN(H ❑ 6.OTHER GENERATORFUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 43% CONTENTS PETROLEUM: 19 Ia.REGULAR UNLEADED ❑ Ic.MIDGRADEUNLEADED ❑ Ib.PREMIUM UNLEADED 446 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S i : 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL Ej 11.OTHER NON-PETROLEUMS i ): 446h IV. TANK CONSTRUCTION TYPE OF TANK 01.SINGLE WALL N 2.DOUBLE WALL 095.UNKNOWN 443 PRIMARY CONTAINMENT 0 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN IR99.OTHER S i ):FJCJP44m SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LIBER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN 2.BALL 99.OTHER(Specify) P 445a OVERFILL PREVENTION I.AUDBLE&VISUALALARMS FLOAT U 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-WALLED2.DOUBLE-WALLED ❑99.OTHER 466 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY C33.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR§2636(e)(3)1 458 PRIMARY CONTAINMENT U I.STEEL ❑ 4.FIBERGLASS ❑ a.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN al 99.OTHER(Specify): Cff 464. SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN 99.OTHER(Specify): a64r PIPINGTFURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 464L VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ® L STEEL ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC 0 W.NONE 0 99.OTHER(Specify) 964e 469e1 VENT SECONDARY CONTAINMENT go 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Sp Ify) 464r 'tMit VR PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specif)r) 4646 464 I VR SECONDARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) tMh 4 hl VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL 0 2.DOUBLE WALL 2L 90.NONE 4641. RISER PRIMARY CONTAINMENT (SI 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 ,IMil RISER SECONDARY CONTAINMENT 1.STEEL El 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 1399.OTHER(Specify) 4Mk 464kl FILL COMPONENTS INSTALLED M 1.SPILL BUCKET 0 3.STRIKER PLATEBOTTOM PROTECTOR X 4.CONTAINMENT SUMP 451e-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469^ CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS J@ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bc VIII. CORROSION PROTECTION 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 full com Bance wfN 1 al re irements. APPLICANT SIGNATURE DATE J70' APPLICANT NAME(prinQ 411' APPLICANT TITLE 4T__ Rt) 14tFMG •r UPCF UST-B-12 Rev.(12/2007)