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v IIIA UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK 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) 430 ❑ 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: 430a 1 DATE EXISTING UST DISCOVERED: 4Mb I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 BUSINESS SITE ADDRESS103 CITY IN 2 w- i%E e_ MAI+%R C44 J-53>' 7 II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 .� ,rye 1.A STAND-ALONE TANK ovv)pn G1 2.ONE IN A COMPARTMENTED UNIT. C lac one efir each com adman in arc umt. DATE U$ S M INSTALLED 435 TANK CAPACITY M GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 433 (2 om III.TANK USE AND CONTENTS TANK USE g Ia.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Indo Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL MSC 425281.5(c)1 ❑ 6.OTHER GENERATOR FUEL Cl 95.UNKNOWN ❑ 99.OTHER(Specify): 43% CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ia MIDGRADEUNLEADED ❑ Ib.PREMIUM UNLEADED 440 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S i : 440' NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 11.OTHER NON-PETROLEUMS i : 44ab IV. TANK CONSTRUCTION TYPE OF TANK ❑ L SINGLE WALL IN 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER p J� 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN 99.OTHER S ' ): R e444a SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN 99.OTHERS i ): FR 445a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHIIT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑I.SINOFF-WALLED 2.DOUBLE-WALLED 099.OTHER 4W SYSTEM TYPE I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLEp ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN 99.OTHER(Specify): 91f� 464. SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE n El 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN 99.FITHER FsNcify): Ri' 464c PIPINGrFURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC CR 90.NONE 0 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC IN 90.NONE ❑ 99.OTHER(Specify) 464f 464(1 VR PRIMARY CONTAINMENT 0 I.STEEL ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC 11190.NONE ❑ 99.OTHER(Specify) 4646 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 4Mh 464hl VENT PIPING TRANSITION SUMP TYPE Q I.SINGLE WALL 0 2.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT W 1.STEEL 0 4.FIBERGLASS U 10.RIGID PLASTIC Us WE NONE U W.OTHER(Specify) 464, 464'1 RISER SECONDARY CONTAINMENT ❑ I.STEEL 0 4.FIBERGLASS 0 Io.RIGID PLASTIC 90.NONE CI 99.OTHER(Specify) 464t 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 0 3.STRIKER PLAT&BOTTOM PROTECTOR IN 4.CONTAINMENT SUMP 451a-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE LSINGLE WALL El 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL L STEEL ❑ 4.FIBERGLASS K 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION aa8 IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in fuB com B ce witinegal requirements APPLICANT e uirementsAPPLICANT SIGNATURE DATE 430, APPLICANT NAME(print) 471' APPLICANT TITLE 472. UPCF UST-8-1/2 Rev.(12/2007)