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RECEIVE® "A .; nil UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK ENVIRONMENTAL OPERATING PERMIT APPLICATION-TANK INFORMATION(0*Qhi&j es tl�,'".RTMENT TYPE OF ACTION (Check one item only. Vo r anJJST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 430 ❑ 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: a3O1 DATE EXISTING UST DISCOVERED: 430b T..)FACILITY INFORMATION, FACILITY ID 4(Agency Use Only) _ 1 BUSINI~SS NANIE(Same as FACILITY NAME or DAA-Doing Business As) 3 >Q S r N ES f 6 BUSINESS SIVE ADDRESS 103 CITY 104 II.TANK DESCRIP'T'ION. , TANK ID# ../a�/� TANK MANUFACTURER 433 TAN CONFIGURATION: THIS TANK 1S 434 l A O I O - �A STAND-ALONE TANK 2.ONE IN A COMPARTMENTED UNIT. complete 0"0age Ibf 4ch com aAmem jn the emit DATE UST SYSTEM INSTALLED 435 TANK CAPAJITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 O 00 TIL TANK:USE A.ND.CONTENTS ., TANK USE le,MOTOR VEHICLE FUELING ❑ Ib.bJARJNA FUELING ❑ lc.AVIATION FUELING 430 ❑ 3,CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes used oil) ❑ S.EMERGENCY GENERATOR FUEL[KSC 17501.5(c)I ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify)! 439a CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEAPED ❑ Ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 WT DIESEL ❑ 5,JET FUEL ❑ 6,AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S ci ; 440& NON-PETROLEUM!❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM 5 cci 4006 IV. -TANK CONSTRUCTION' TYPE OF TANK C3 t.SINGLE WALL ice.DOUBLE WALL El 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL J;'3,FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7,$TEEL+INTERNAL LINING ❑ 95,UNKNOWN ❑ 99.OTHER (Specify): 4440 SECONDARY CONTAINMENT ❑ 1.STEEL En.FIBERGLASS ❑ &EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 443 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(SPccify: 445a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS E] 2.BALL FLOAT FILL TUBE SHUT-OFF VALVE 452 ❑ 4,TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE;PIPING CONS'T'RUCTION PIPING CONSTRUCTION ❑1,SINGLE-WALLED .DOUBLE-WALLED ❑99,OTHER 460 SYSTEM TYPE En,PRESSURE2.GRAVITY Ll 3,CONVENTIONAL SUCTION [14.SAFE SUCTION[23 CCR§2636(a)(3)1 45s PRIMARY CONTAINMENT ❑ L STEED. 4.FIBERGLASS ❑ II.FLEXIBLE ❑ 10.RIGID PLASTIC aha ❑ 90.NONE [125.UNKNOWN ❑ 99.OTHERS ci � 4640 SECONDARY CONTAINMENT ❑ L STEEL Rr4,FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIOIO PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99,OTHER(Specify): 464e PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1,SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90,NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/.FILL PXPE PIPING CONSTRUCTION.. VENT PRIMARY CONTAINMENT id ].STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90,NONE ❑ 99.OTHER(Specify) 4640 464c1 VENT SECONDARY CONTAINMENT Rri.STEEL gF4.MEFGLASS ❑ 10.RIGID PLASTIC 0 90.NONE El 99,OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10,RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 4648 "4g)_ VR SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10,RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464h I VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 464i. RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99,OTHER(Spccify) 4641 464'I RISER SECONDARY CONTAINMENT 1.STEEL L) 4,FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE [J 99,OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED RrI.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP OStew VII:UNDER,TDISX'ENSER CONTAINMENT UAC) CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3,NO DISPENSBAS ❑ 90.NONE 46h CONSTRUCTION MATERIAL ❑ 1.STEEL FT 4.FIBERGLASS ❑ 10,RIGID PLASTIC ❑ 99.OTHER(Specify) 4696 c VIT1.. CORROSION PROTECTION STEEL COMPONENT PROTECTION p 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6,ISOLATION 608. IX. APPLICANT SIGNATURE CERTIFICATION: I certify,th tbis UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full nce with I al rc uirements APPLICANT SIGNATURE DATE v' Z( ` 3 a7o. APPLICANT NAME(pr 1) 07). APPLICANT TITLE ll472. UPCF UST-B-112 XU-(IZ'2007) e .