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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERA APPLICATION-TANK INFORMATION O,w form per us TYPE OF ACTON (Check one item only. Form UST permarl closure or removal,complete only this section and Sections I,II,UL IV,and UC below) 450 ❑ 1.NEW PERMIT ®3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION El 6.TEMPORARY UST CLOSURE. ❑ 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 9JOe DATE EXISTING UST DISCOVERED: -� 4MI. FACILITY INFORMATION 5�0-I 3 I IS t6i FACILITY ID It(Agency Use Only) BUSINESS NAME(Sema as FACILITY NAME or DBA-Doing Business As) 3 Cel en -Sf4-fes O s/;.f n . >4 r{/ 4 Si-��S a/E w I/ ✓i a /wt• i� BUSINFSSSITEADDRESg� 103 CITY 1 1 /y./i ..[. /Q•aa/ .CA A1n EL TANK DESCRIPTION TANK IDN 612 TANK MANUFACTURER 451 TANKCONFIGURATION:THISTANKIS 454 A STAND-ALONE TANK 2.ONE M A COMPARTMENTED IMT. 4n�cAlW n w• h Cs l.maw fb,arh rom mN5 i0:6sunil DATE UST SYSTEM INSTALLED 455 TANKCAP CRY INGALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 452 yW' .. a. � If TANK USE AND CONTENTS TANKUSE ❑ Is.MOTOR VEHICLE FUELING ❑ ib.MARINA FUELING ❑ Ia AVIATION FUELING 419 (1 3.CHEMICAL PRODUCT STORAGE ).4.HAZARDOUS WASTE(Isdafa Ua60i0 ❑ 5.EMERGENCY GENERATOR FUEL INSC 4u2t1.5(c)] ❑ 6.0THER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 43% CONTENTS PETROLEUM: ❑ is.REGULAR UNLEADED ❑ I.MIDGRADEUNLFADED ❑ Ib.PREMIUMUNLEADED 440 ❑3.DIESEL ❑S.JET FUEL ❑ CAVIATION GAS ❑&PETROLEUM BLEND FUEL 9.OTHFR PETROLEUM mi /N L No. NON-PETROLEUM:a 7.USEDOIL t0.ETHANOL ❑ 1 LOTHER NOK PETROLEUM(Specify); 44ob IV. TANK CONSTRUCTION TYPE OF TANK I SIRGLE WALL ❑2.DOUBLE WAD. ❑93.UNKNOWN 643 PRIMARY CONTAINMENT ❑ I.STEEL ❑3.FIBERGLASS ❑6.INTERNALBLADDER ❑ 7.STEEL+INTERNALLININO ❑95.UNKNOWN ❑ W.OTHER SECONDARY CONTAINMENT 13 LSTEEL ❑3.FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER EleDP� IIs [190.NONE ❑95.UNKNOWN ❑99.OTHER S i is OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS 2.BALLFLOAT 3.FILLTUB SHUT-OFF VALVE 453. ❑4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V, PRODUCT/WASTE PIPING CONSTRUCTION al PIPf4GCONSTRUC7TON ❑I;SINGL&WALLED ❑2.DDUSLE.WALLED 099.OTHER 660 SYSTEM TYPE ❑ I.re=bvRB ❑ 2GRAV1'fY ❑ 3.CONVENIIONALSUCTION ❑4.SAFE SUCTION fn CB 42656(-0(3)) 456 PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ T0.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.0THER(S ily): 464. SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ &FLEXIBLE ❑ 10.11IG(DPLASTIC WIS [190,NONE ❑ 95.UNKNOWN ❑ 99.OTHER S ify): _ 4610 u PIPINOf111R6INECONTAMMENT SUMP TYPE ❑ I.SINGLEWALL ❑2.DOUBLE WALL U NONE 46ad VL VENT,VAPOR RECOVERY )ANDRL4ER/FILLPIPEPIPINGCONSTRUCTION . VENT PRIMARY CONTAINMENT I.STEEL ❑4.RBERGLAS3 to RIGIDPLA311C LlW.NONfl 99.OTHER 466^ 464.1 VENT SECONDARY CONTAINMENT ❑ LSTEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE_ 99.OTHER(Specify) 461"0n VR PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Spedfy) 4616 460 I VR SECONDARY CONTAINMENT I.STEEL 4.FIBERGLASS I0.RIGID PLASTIC 90.NONE ❑99.OTHER(Speafy) 464h 4Whl VENTPIPINO TRANSt710N SUMP TYPE 1.3INOL6 WALL I.OOUBLH WALL ❑ 90.NONE 664E RISER PRIMARY CONTAINMENT I.STEEL Lj 4.FIBERGLAS, 10.TION PLASTIC 90.NONE ❑ 99.OTHER(Spaify) 4641 461'1 RISER SECONDARYCONTAMMENT 1.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC I 90.NONE 13 99.OTHER(SPedfy) 4644 460 I FILL COMPONENTS INSTALLED 0 ).SPILL BUCKET 3.STRUCER PLATBIBOTTOM PROTECTOR LJ4.CONTANMENTSUMP 155w VII.UNDER DISPENSERCONTAINMENT(UDC) CONSTRUCTION TYPE [31.SINGLE WALL ❑2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469. CONSTRUCTIONMATERIAL U I.STBEL ❑4.FIBERGLASS ❑ 10.RIONPLASTIC ❑ 99-07NEKVPOCIM 6696'0 VIII. CORROSION PROTECTION STEEL COMPONENTPROTECf10N ❑ 2.SACRIFICIAL ANODES) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION H& DL APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hamrdous substance stared and that the Information provided herein 6 true,accurate, end In till com 920. APPLICANT SIGNA DATE APPLICANT NAMEforiW ��/Z42L A?PLICANT TILE 4n lel UPCF UST-B-112 Rev.(122007)