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63 A UNIFIED PROGRAM CONSOLIDATED FORM ,� d UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. For UST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 430 ❑ ].NEW PERMIT3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a 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 BUSINESS SITE ADDRESS 103 CITY 104 o G Wa S�oal�ro IL TANK DESCRIPTION TANK ID#'�n��1aa.(� 432 TANK MANUFACTURER a33 TANK CONFIGURATION: THIS TANK IS 434 _ !N�! r ALONE TANK r (�n I G{1 (`L rr D / �r .ONE IN A COMPARTMENTED UNIT. Q �+C� Co lete one a for each tin the emit DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GLLONS 436 NUMBER OF COMPARTMENT'S IN THE UNIT 437 HL TANK USE AND CONTENTS TANK USE la MOTOR VEHICLE FUELING [IIb.MARINA FUELING ❑ Ic.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC¢25281.5(c)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: la-REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED [Ilb.PREMIUM UNLEADED 440 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9-OTHER PETROLEUM S 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(S 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ L SINGLE WALL 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 ❑ 1.STEEL W.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION ❑ 1.AUDIBLE 8t VISUAL ALARMS UR 2.BALL FLOAT [�3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENT'S FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED 2.DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE 14 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR J2636(ax3)I 458 PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT Ll 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC M 90.NONE ❑ 99.OTHER(Specify) 464f 464fl VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 464g 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC M 90.NONE 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL KI 90.NONE 4641. RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 4641 RISER SECONDARY CONTAINMENTIffL STEEL ❑ 4.FIBERGLASS [110.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464r 4641 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 0 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a< VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL 0 1.STEEL ❑ 4.FIBERGLASS 10 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b-a VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 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 compliance with legal requirements. APPLICANT SIGNATURE DATE Q 470. APPLICANT NAME(print) 471" APPLICANT TITLE an. c UPCF UST-B-1/2 1 Rev.(12/2007)