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• • RECEIVE® UNIFIED PROGRAM CONSOLIDATED FORM FEB 14 2014 UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One L PF ACTION (Check one item only. For an UST permanent closure orremoval,complete only this section and Sections I,II,III,N,1 �941�EPARTM 1.NEW PERMTT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF MO. ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 43f° 1 DATE EXISTING UST DISCOVERED: 430b L FACILITY INFORMATION FACILITY TO#(Agency Use Only) _ _ 1 BUSINESS NAME(Same as F CILRY NAME or DBA-Doing Business As) 3 W tis BUSINESS SITE ADDRESS /I r O��'Tr 4, ,E Ina CITY H _ \ G A �� loo �1 r 1! 11.TANK DESCRIPTION T" TANK ID# 0,�> C 432 TANK MANUFACTURER 433 TA FoNFIGURATION: THIS TANK IS 434 A STAND-ALONE TANK ❑2.ONE IN A COMPARTMENTED UNH. canpine we paIc for each conunnaner,in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 000 III,TANK USE AND CONTENTS TANK USE PrI..MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL(HSC§25al.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439. CONTENTS PETROLEUM: Ia.REGULAR UNLEADED ❑ 1c.MIDGRADE UNLEADED ❑ III.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON.PETROLEUM(Specify): Mob IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL Er5.DOUBLEWALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT1.STEEL [1 [13.FIBERGLASS 6.INTERNAL BLADDER f� 444 E 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 4a4a SECONDARY CONTAINMENT 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETEDIff 445 90.NONE ❑ 95.UNKNOWN [199.OTHER(S ): 495a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT 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-WALLED 9.2.DOUBLE-WALLED [199.OTHER 40 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR§2636(a)(3)] 458 PRIMARY CONTAINMENT 1.STEEL Oq 4.FIBERGLASS [IS.FLEXIBLE EI10.RIGID PLASTIC 464 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ I.STEEL )W 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464h ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464e PIPING/T'URBINE CONTAINMENT SUMP TYPE WLSINGLEWALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4Nd VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL Xj 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4Me 464.1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC W90.NCNE ❑ 99.OTHER(Specify) 464( 464n VR PRIMARY CONTAINMENT ❑ 1.STEEL OQ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 4&ISI VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC AI 90.NONE ❑ 99.OTHER(Specify) 4Mh 464hl VENT PIPING TRANSITION SUMP TYPE L SINGLE WALL 2.DOUBLE WALL 90.NONE 464i. RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS LJ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 464'1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4644 'IMk1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451st VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS [190.NONE 46% CONSTRUCTION MATERIAL ❑ 1.STEEL EW4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b< VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 10 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 commIiance with Ie al re uirements. APP ATU DATE 470. APP AN t) 411' APPLICANT TITLE A 4n. v GLa^ Q l4�h Y UPCF UST-B-1/2 Rev.(12/2007)