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RECEIVE® UNIFIED PROGRAM CONSOLIDATED FORM AUG 0 5 2013 UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION TYPE OF ACTION (Check one item only, For as UST permanent closure or removal,complete only this section and Sections I,II,III,I A-aMl:IXbeldWARTM E Rt ❑ 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 U5T DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) a :. _ 0 a 0 _ ` y BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FAs T N E-41,6 BUSINESS SITE ADDRESS 103 CITY - 104 a q 33 b IL:TANK DESCRIPTION',:_ . TANK ID# 32 TANK MANUFACTURER 433 TANK CONFIGURATION; TFIIS TANK IS 434 0 I�.A STAND-ALONE TANK. b 41a7eM� 60V"A1-j.'� ❑2.ONE INACOMPARTMENTEOUNIT. Com ia.e ane R29efar each com arlment in the Uf t DATE UST SYSTEM INSTA LED 475 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 v 10 ^ 3� l0 0OID III.TANK USE AND,CONTENTS TANK USL a.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ It,AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT sTORA.G8 ❑ 4.HAZARDOUS WASTE(locmdee U.ed oil ❑ S.EMERGENCY GENERATOR FUEL[HSC§25291.5(e)j ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify)! 439a CONTENTS PETROLEUM; Gler..REGULAR t3NLEADED ❑ le.MIDGRADE UNLEADED ❑ lb,PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ SAET FUEL ❑ G,AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9,OTHER PETROLEUM (Specify): 4-00a NON-PETROLEUM:❑ 7,USED OIL ❑ 10.ETHANOL ❑ IL OTHER NON-PETROLEUM(Specify); 440E IV:,:TANK CONSTRUCTJON :. TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ I.5715'1 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify); 444a SECONDARY CONTAINMENT ❑ I.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE. ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS ❑ 2,BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 412• ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V:.T'RODUCT/WASTE PIPING CONSTRUCTION. PIPING CONSTRUCTION ❑1.SINGLE-WALLED EM,DOUBLE.WALLED ❑99.OTHER 460 SYSTEM TYPE R-T.PRESSURE ❑ 2.GRAVITY 3.CONVENTIONAL SUCTION ❑ 4,SAFE SUCTION[23 CCR t26364 3 458 PRIMARY CONTAINMENT ❑ I.STEEL R-f FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95,UNKNOWN ❑ 99.OTHER(S eci ): 464a SECONDARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS ❑ 8,FLEXMLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4640 PIPINOTURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d .: LVENT VAPOR RECOVERY(VR AND RISER/FILL PIPE,PIPIN6.CONSTR07TIW. VENT PRIMARY CONTAINMENT STEEL Er4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99,OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT STEEL 4.FIBERGLASS ❑ IO.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 464f a64f1 VR PRIMARY CONTAINMENT ❑ I.STEEL a�,I.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ ".OTHER(Specify) 464S 464•I VR SECONDARY CONTAINMENT ❑ 1,STEEL ❑ 4,FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464h 464bl VENT PIPING TRANSITION SUMP TYPE D 1.SINGLE WAIL 2.DOUBLE WALL 0 90,NONE 464h• RISER PRIMARY CONTAINMENT 1,STEEL ❑ 4.FIBERGLASS U 10.RIGID PLASTIC ❑ 90.NONE ❑ 99,OTHER(Specify) 4641 464i1 RISER SECONDARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 PILL COMPONENTS INSTALLED 011.SPILL BUCKET 3.STRIKER PLATEMOTTOM PROTECTOR 4.CONTAINMENT SUMP 4514-4 VII,UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SINGLEWALL [] 2.DOUBLE WALL ❑ 3.NO DISPENSERS [390.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(S ecify) <69b 4 VIII. :CO"OSION.PROTEC`I'ION . STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE ' x . CERTIFICATION, I certify tha this UST system is compatible with the hazardous substance stored and that the information Drovtded heftly;isirue,accurate, and in full ante with legal rc ulrements. APPLICANT SIGNATURE DATE 470. APPLICANT NAME(prin 471' APPLICANT TITLE 4n. UPCF UST-B-1/2 R 121ZO07)