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� o UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. Form UST peram ent closure or removal,complete only this section and Sections 1,B,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 0 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 43aDATE EXISTING UST DISCOVERED: 430b L-FACE ITY INFORMATION. FACILITY ID q(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 aTJ 02 BUSINESS SITE ADDRESS l03 4�a -w oSEa1l�.E vF �"� �q ft -TE�y 1W EL TANK DESCRIPTION TANK 11)H 432 TANK MANUFACTURER 433 1 TAW CONFIGURATION: THIS TANK IS 434 r t�r.A STAND-ALONE TANK Xy g. }C�j )M 2.ONE IN A COMPARTMENTED UNIT. C eu one for eerb m0suri4. DATE UST SYSTEM INSTALLED 435 ANIK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN TIME UNIT 437 'k4l9well, III.TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(mc Us a]) ❑ 5.EMERGENCY GENERATOR FUEL[HSC 425281.5(.)] [16.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ I..MIDGRADE UNLEADED e"I b.PREMIUM UNLEADED HO ❑ 3.DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM $ i : MW NON-PETROLEUM:❑ 7.USED OI. ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUMS i : 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL @'2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL 91 FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING 11991 95.UNKNOWN ❑ 99.OTHER 414a SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER -OL 7.]ACKEfED 445 1190.NONE ❑ 95.UNKNOWN ❑99.OTHER(S 445a OVERFILL PREVENTION (.AUDIBLE&VISUAL ALARMS ):2.BALLFLOAT 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRO DU t WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED 2.IR)IIBIE-WALLED ❑99.OTHER 460 SYSTEM TYPE I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR¢2636(a(3B 458 PRIMARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL (a"4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. PIPINGITURBINE CONTAINMENT SUMP TYPE ❑ I.SINGLE WALL 02 DOUBLE WALL ❑ 90.NONE 4W VI.VENT;VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 1.STEEL Erk FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 464. VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 464e) OTHER(Specify) 464f VR PRIMARY CONTAINMENT ❑ 1.STEEL Erk FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE CI 99.OTHER(Specify) 4MII 4Mg 46 I VR SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE D 99.OTHER(Specify) 46th 46461 VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL 2.DOUBLE WAIL 0.NONE 4641. RISER PRIMARY CONTAINMENT LkI.STEEL 4.FIBERGLASS U 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464] 464'1 RISER SECONDARY CONTAINMENT ❑ L STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 0.NONE 0 99.OTHER(Specify) 464k 464111 FILL COMPONENTS INSTALLED Cr1.SPILL BUCKET Ll 3.STRIKER PLATFIBOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 451st VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE Ed-1.SINGLE WALL ❑ 2.DOUBLE WAIL ❑ 3.NO DISPENSERS ❑ 90.NONE 469. CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS 12'10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION "II. UL 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 fug compliance with legal requirements. APPLICANT SIGNATURE /) DATE 470. I O4--06 /D APPLICANT NAME(print) 471' 1 APPLICANT TITLE 472 r UPCF UST-B-12 Rev.(12/2007)