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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT'APPLICATION-TANK INFORMATION(One form per UST) -fYPh 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 '59 1.NEW PERMIT ❑ 3.RENEWAL PERMIT [15.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE S.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4304I DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 SR P4 Y-QA 9 0 1 N BUSU40S SITE ADDRESS 103 CITY moa S Tp H.TANK DESCR MON TANK W# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 C O N -7-A!IV In JE n/7' a].A STAND-ALONE TANK (J T 1 5 a L V?'1 o hl S [--]2.ONE IN A CowARTmE NTED UNIT. C=plete one page for e.ch- �w in the umc DATE UST SYSTEM INSTALLED 433 TANK CAPACITY IN G LLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 o L G>.AV C III.TANk USE AND CONTENTS TANK USE :ff la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(1-hide Uxd Oil) ❑ S.EMERGENCY GENERATOR FUEL(HSC 425281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439. CONTENTS PETROLEUM: ja la.REGULARUNLEADED ❑ Ic.MIDGRADEUNLEADED ❑ lb.PREMIUM UNLEADED 440 0 3.DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11,OTHER NON-PETROLEUM(Specify): 4406 N. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL Z 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL $ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT 0 1.STEEL baa.FIBERGLASS 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S i ): 4454 ✓ERFILL PREVENTION 1.AUDIBLE&:VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTIONUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED 13 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(aX3)) 458 PRIMARY CONTAINMENT ❑ 1.STEEL [1 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464& SECONDARY CONTAINMENT ❑ ].STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/IURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS El 10,RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT E3 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE M 99.OTHER(Specify) 464s 464z 1 VR SECONDARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 4646 46461 VENT PIPING TRANSITION SUMP TYPE 0 1.SINGLE WALL 2.DOUBLE WALL 0 90.NONE 464L RISER PRIMARY CONTAINMENT l;V 1.STEEL Lj 4.FIBERGLASS 0 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464i 464'1 RISER SE(:oNDARY CONTAINMENT ❑ 1.STEEL tj 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 464k 464kl FILL COMPONENTS INSTALLED I.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR JS 4.CONTAINMENT SUMP 4514rc VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL, 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 449. 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 hull compliance with legal r u _,PLICANT SIGNA DATE 470. APPLICANT NAME(print) P��.�-�s a n� 4 n APPLICANT TITLE -r Y��j Gs-T-ry� arz nvry ncr_u_3 r7 Rev_(12/2007)