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3r - 0 , UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One Foran per UST) TYPE OF ACRON (Check one item only. For an UST permanent closure or removal,complete only this section �eriidnsi�N,J4I Y, D(below) 430 ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5. r�NP,y6QI [NFbTN y __ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE - ❑ 8.>!1S M03Y L '�1 '�� j DATE UST PERMANENTLY CLOSED: d30i I DATE EXISTING UST DISCOVERED: -' 4306 L FACILITY INFORMATION FACILITY ID 0(Agency Use Only) 1 BUSINES TE c($amepsI "�VACILrrY NACMEQ ✓ BW qS' i,\ AS) - - 3 BUSINESS S1TE AS r D�e!'ru yP /ycA..P 'm cITY �'ile[7442 GF1 101 � IL TANK DESCRIPTION TANK IV-- �/- Q 02 TANK MANUFACTURER 433 TANKCONPIOURATION: THISTANKIS 4M T A JG� T [(�C ANK ONIMACO PM ARTMENTEDUNIT. Pore w in4 wit DATE UST SY$TEy f1§fALLED o3 TANK ACTTY RECONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 �� /''!I 99 tH.TANK USE AND CONTENTS TANK USE 6 MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ le.AVIATION FUELING 439 3 CHEMICAL PRODUCT STORAGE ❑ 4.HA7ARDOUSWASTE(Wn Us4oi0 ❑ 5.EMERGENCY GENERATOR FUEL lose ❑ 6,OTHER GENERA RFUEL 11 95.UNKNOWN gZSul.Nc)1 CON'TENT'S PETROLEUM UNLEADED ❑ I&OTHER(Specify): 459a ❑ Ie.MIIX)RADE[1NLEADED ❑ Ih.PREMIUM UNLEADED as .DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS U S.PETROLEUM BLEND FUEL 11 9.OTHERPETROLEUM S Nae NON-PETROLEUMS 11 7.USED OIL 11 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM S eci : Nay IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL IS 2.DOUBLE WALL 11 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL Ll 3.FIBERGLASS [16.INTERNAL BLADDER 444 19 ].STEEL+INTERNAL LINING 11 95 UNKNOWN ❑ 99 OTHER S 4W SECONDARY CONTAINMENT Q 1.STEEL 113.FIBERGLASS CKC EXTERIOR MEMBRANE L 11 7.JACKETED a5 C-) 90. NE 11 95.UNKNOWN 1199.OTHER S i _ ase OVERFILL PREVENTION .AUDIBLE&VISUAL ALARMS 2.BALL FLOAT .FILL TUBE SHUT-OFF VALVE 452 ` ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/yASTF PIPING CONSTRUCTION PIPING CONSTRUCTION ❑LSINGLE-WALLEDUBLE-WALLED 099.0THER 460 SYSTEM TYPE Ejr.PRESSURE ❑ 2.GEAVITY 11 3.CONVENTIONAL SUCTION PRIMARY CONTAINMENT ❑ L STEEL pR�A D 4.SAFE SUCTIGN In CCR 97436(a 3 45e 11 90.NONE ❑ 8.FLEXIBLE ❑ 10.RIGm PLASTIC 464 ❑ 95.UNKNOWN 1199.OTIB2(Speeify}. 464a SECONDARY CONTAINMENT ❑ I.STEN. ERGLASS 11 8.FLEXIBLE [0] 10.RIGID PLASTIC 46W 11 90.NONE ❑ 95.UNKNOWN 11 99.OT'HER(Spedfy): 464c PIPINGTTURBINE CONTAINMENT SUMP TYPE ULE WALL 2.DOUBLE WALL ❑ 90.NONE 4W VI.VENT;VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 1199.GTHER(Specify) ab4e VENT SECONDARY CONTAINMENT _ 1.STEEL ® 4.PIBERGLASS �e1 • ❑ lO.RIGm PLASTIC 90.NONE 1199.OTHER(Spcafy) 4WF 46an VRPRGfARY CONTAINMENT )4T LSTEEL 4.FIBERGI,A3S IO.R[Cm PLASTIC 90.NONE 99.OTHER(Spedfy) 4649 D _ VR SECONDARY CONTAINMENT 1.STEEL Q 4.PIBERCd.hAS ❑ 10.RIGID PLASTIC ❑ 90.N ❑ 99.OTT3I±R(Spewfy) 469y VENT PIPING TRANSITION SUMP TYPE I.SINGLE WALL 2.DOUBIE WAIL .NONE .- 969h1 0 611. RISER PRIMARY MN AIA4ENT C 0.1.STEEL 4.FIBERGLASS 1RIGID PLASTIC W.NONE (Sp-*)99.MIR 44Mj l RISER SECONDARY CONTAINMENT '1.STEEL 4.F®ERGLASS IO.RfGm PLA3T"[C 90.NONE 99.OTHER(Spvafy) .aW 46441 FILL COMPONENTS INSTALLED 1.SPELL BUCKET 3.STRIKER PLA"TE/BO'CKXM PROTE(.TOA 4.CONTAIJ[o¢NT'SIJMP 451. UNDER DISPENSER f,9XTAINMENT(UDC) CONSUCTION TYPE OLE WALL .UBLE WALL ❑ 3.NO DISPENSERS ❑ W.NONE 46% CONSTRTRUCDON MATERIAL LgeLMIEtL U 4.FIBERGLASS '�Q I0.RIGID PLASTIC 99.O1HER 5 4696c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT SOLATION 448. DG APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system E compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full compliance with I aI irem¢ufa. APPLICANT SIGN DATE /� ,ZO 4V APPLICANT N APPLICANT �6 'f 4n �V Ga/U LeatJ•p .E+�Cm.{7 UPCF UST-R-I2 eo.s•p V Rev.(122007)