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0( MAO ra. p UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Cbcck one item only. Foran UST permanent closure or removal,complete only this section and Sections I,11,III,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 ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4302 1 DATE EXISTING UST DISCOVERED: 4306 L•FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 BUSINESS SITE ADDRESS t03CITY 101 _w aSFm'r II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK NK COGURAIION:THIS TANK IS 434 JW. .A STAND-ALONE TANK ONE IN A COMPARTMENTED UNR. CO eteene forearhwm an in tlswdL DATE UST TSSYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPAR 437 JI 1600 .TANK USE AND CONTENTS TANK USE 0 Ia.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ le.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Inch"UW Oil) [3 5.EMERGENCY GENERATOR FUEL fESC§8281.5(.)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 4392 CONTENTS PETROLEUM: 5T Ia.REGULAR UNLEADED ❑ lc.MIIIGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL (] 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 4402 NON-PETROLEUM:❑ 7.USED OIL ❑ I0.ETHANOL 11.OTHER NON-PETROLEUMS i : 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN M3 PRIMARY CONTAINMENT ❑ I.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S c' 4442 SECONDARY CONTAINMENT ❑ I.STEEL .FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.3ACKETED HS ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S i ): 4452 OVERFILL PREVENTION 1.AUDIBLE @VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 451. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V.PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED ©1.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVrfY ❑ 3.CONVENTIONAL SUCTION ❑4.SAFE SUCTION 123 CCR 6263003)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Spm*): 469a SECONDARY CONTAINMENT ❑ I.STEEL Cr4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4546 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. PIPING?URSINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL .DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS El 10.RIGID PLASTIC 90.NONE El 99.OTHER(Specify) 46ae 464e1 VENT SECONDARY CONTAINMENT 0 1.STEEL gr4.FIBERGLASS 0 10.RIGH)PLASTIC 0 90.NONE 0 99.OTHER(Specify) 464f 4640 VR PRIMARY CONTAINMENT ❑ 1.STEEL W4.FIBERGLASS ❑ 10.RIGH)PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4649 'IM21 VR SECONDARY CONTAINMENT ❑ 1.STEEL E'4.FIBERGLASS ❑ 10.RIGH)PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4Mh 464h1 VEIN PIPING TRANSITION BUMP TYPE Q 1.SINGLE WALL 0 2.DOUBLE WALL 0 90.NONE a64i. RISER PRIMARY CONTAINMENT 16 1.STEEL U 4.FIBERGLASS LJ 10.RIGH)PLASTIC U 90.NONE Lj 99.OTHER(Specify) 464j 459'1 RISER SECONDARY CONTAINMENT 0 1.STEEL ❑ 9.FIBERGLASS 0 10.RIGH)PLASTIC .NONE 0 99.OTHER(Specify) 4612 46 FILL COMPONENTS INSTALLED .SPILL BUCKET D 3.STRIKER PLATE/BOTTOM PROTECTOR 04.CONTAINMENT SUMP 431a<. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE L SINGLE WALL 0 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469. CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS '4(2^10.RIGID PLASTIC ❑ 99.OTHER(Specify) 2696. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448 DL 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 to Ng compliance with legal requirements. APPLICANT SIGNATURE ` DATE ��- 0 470. APPLICANT NAME(prinQ 471' APPLICANTTITLE 4n. H UPCF UST-B-1/2 Rev.(12/2007)