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RECE"�!� jl ,OWSpQ �•/.ac UNIFIED PROGRAM CONSOLIDATED FORNI ,.- 1`1 UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION'(One form per UST) TYPE OF ACTION (Check one item only. For ST permanent closure or removal,complete only this section and Sections I,U,III,IV,and IX below) 430 El 1.NEW PERMIT 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ S.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4304 DATE EXISTING UST DISCOVERED' 430b L FACILITY INFORNIATWN FACILITY ID#(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAME or DSA-Doing Business As) a 9 4f 1 6 J3USINES$SITE ADOkESS 103 CITY 104 II.TANK DESCRIPTION F. TANK ID!J 432 TANK MANUFACTURER 433 TAN CONFIGURATION: THIS TANK IS 434 ASTAND-ALONETANK ��tA_& CV r t4'1.A3 ❑2.ONE IN A COMPARTMENT130 UNIT, Com etc one page for each cum artmwt in the unit. DATE UST SYSTEM INSTALLED 411 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 10 -389 �D ooh 1 III:TANK USE AND CONTENTS TANK USE la.NIOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ 1c.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4,HAZARDOUS WASTE(locledes Used Oi]) ❑ 5.EMERGENCY GENERATOR FUEL(HSC J252e1.3(c)l ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99,OTHER(Specify): 439. CONTENTS PETROLEUM' ❑ Ia.REGULAR UNLEADED ❑ Ic,MIDGRADEUNL£ADED B11b.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5,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(MS eci : 44b IV. TANK CONSTRUCTION TYPE OF TANK ❑ L SINGLE WALL 53'2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL Wo,FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL�INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER S eci 444a SECONDARY CONTAINMENT ❑ 1.STEEL rtr3.FIBERGLASS ❑ 6.EXTERIOR NIEMBRANE LJNER ❑ 7,JACUTED 443 ❑ 90.NONE ❑ 95,UNKNOWN [199.OT14ER(S eci •)' Wit OVERFILL PREVENTION [11.AUDIBLE&VISUAL ALARMS ❑ 2.13ALL FLOAT 3.FILL TLIBE SHUT-OFF VALVE isz ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FRONT OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED HT DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSUIU: ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR§2636(Q)(1)) 438 PRIMARY CONTAINMENT ❑ I.STEEL Er4,FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN Q 99,OTHER(Spcciy): 464a SECONDARY CONTAINMENT ❑ 1.STEEL a.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10,RIGID PLASTIC 4644 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTNER(Specify): 464c PiPINGITURB1NE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL Q 90,NONE 464d VI.VENT;VAPOR RECOVERY(VR)AND RISER/FILL.PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT kr I.STEEL FIBERGLASS U 10.RIGID PLASTIC ❑ 90•NONE ❑ 99,CTHZR(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT Er 1.STEEL 4.FIBERGLASS ❑ 10,RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 464f 4640 VR PRIMARY CONTAINMENT ❑ 1,STEEL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99,OTHER(Sp--ify) 4"4S �8 VR SECONDARY CONTAINMENT 0 1.STEEL ❑ 4.FIBERGLASS ❑ IR RIGID PLASTIC ❑ 9a.NONE 0 99.OTHER(Spocify) 464h 4641 VENT PIPING TP-ANSITIONStJN1P TYPE I.SINGL.EwALI 2.DOUBLE WALL O.NONE 464i. RISER PRIMARY CONTAINMENT ' SNL ❑ 4.FJBERGLASS 10,RIGID PLASTIC Lj 90.NONE 0 99.OTHER(Specify) 4041 464') RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99,OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED I.SPILL BUCKET FT3.STRIKER PLATEA30TTOM PROTECTOR ❑ 4,CONTAINMENT SUMP d51 a-c VIL UNDER DISPENSER CONTAINMENT(U DQ CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2,DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 9O.NONE 4691. CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b� VIIU. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2,SACRIFICIAL-ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 446. IX. APPLICANT SIGNATURE CERTIFICATION: I certify tha this UST system is compatible with the hazardous substance stored and that the Information provided herein is true,accurate, and lit full 1 ance with legal requirements. DATE ago. APPLICANT SIGNATURE b'l�l►� Ef� T NAME{prin 471' APPLICANT TITLE 673' �t' 4 H�►� Z2 cru{ UPCF UST-13-112 Rev.(1=007)