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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) <br /> TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,11,III,IV,and IX below) 430 <br /> `� 69 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> 6.TEMPORARY UST CLOSURE 1.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 43Qa I DATE EXISTING UST DISCOVERED: 4306 <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) _ I <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 <br /> SAM - 0-06, Q 01 N <br /> 103 CITY 104 <br /> BUSINESS SITE ADDRESS <br /> s-r c1-4 <br /> H.TANK DESCRIPTION <br /> TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 <br /> CC>N7-A1NInof7- 8:1.ASTAND-ALONE TANK <br /> (3,,T 1 '} [12.ONE IN A COMPARTMENTED UNIT. <br /> 'fit"'�•'` S dL V �1 d COMPICIt MC pfigE for each WMpa==t ie the umt. <br /> DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 <br /> p Z e.,19 c. <br /> M.TANOUS2MAND CONTENTS <br /> TANK USE la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439 <br /> 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used 0-1) ❑ 5.EMERGENCY GENERATOR FUEI_[HSC§252815(c)I <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439. <br /> CONTENTS PETROLEUM: 'a la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ ]b.PREMIUM UNLEADED 440 <br /> 0 3.DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 44 Oa <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUM(Specify): 440b <br /> TV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL jg 2.DOUBLE WALL ❑ 95.UNKNOWN 443 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL N 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 440 <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER Sped ): 444. <br /> SECONDARY CONTAINMENT 1.STEEL Ia 3.FIBERGLASS 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S i 445. <br /> OVERFILL PREVENTION L AUDIBLE do VISUAL ALARMS 2.BALL FLOAT 3.FILLTUBE SHUT-OFF VALVE 452. <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION 1.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER 460 <br /> SYSTEM TYPE ❑ L PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR§26W*X3)I 458 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a <br /> SECONDARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464e <br /> PIPING/TURBINECONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d <br /> VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT 0 1.STEEL ® 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464t <br /> 464el <br /> VENT SECONDARY CONTAINMENT ],STEEL ja 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464f <br /> 464(1 <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL 5g 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 <br /> 464 t <br /> VR SECONDARY CONTAINMENT 1.STEEL W 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 4646 <br /> 46461 <br /> VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 4641. <br /> RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 4641 <br /> 464'1 <br /> RISER SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99,OTHER(Specify) 464k <br /> 464k1 <br /> FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATVBOTTOM PROTECTOR 2 4.CONTAINMENT SUMP 431a•c <br /> VII.UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ❑ 1.SINGLE WALL [12.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 4698 <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL <br /> ❑ 4.FIBERGLASS 10.RIGID HAS= [199.OTHER(Specify) 4696` <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIALANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, <br /> and in full compliance with I al r vire <br /> 470. <br /> APPLICANT SIGNATURQ DATE ..r <br /> 472. <br /> APPLICANT <br /> APPLICANT TITLE <br /> APPLICANT NAME(Print) �� 'IF.7. DS O G'C7 <br /> rd 7� (�TQ�, <br />