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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATIOt�ic'3,9eisb''. <br /> TYPE OFACTION (Check one item only. For an PST permanent closure or removal,complete only this section and Sections L.11,Jlf,1V,"and IX below) 430 <br /> ❑ 1.NEW PERMIT Er3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> 6.TEMPORARY UST CLOSURE [1 7.UST PERMANENT CJOSUU ON SITE ❑ 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 43"A I DATE EXISTING UST DISCOVERED: 430b <br /> L FACILITY*INF(j]kMAt.tbr4:,'-,,. <br /> FACILITY ID 4(Agency Use Only) <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Poing Business As) <br /> IA.-Iz:l <br /> BUSINESS SITE ADDRESS 103 CITY 104 <br /> 11.TANK DESCRIPTION <br /> TANK ID# 432 TANK MANUFACTURER 433 TAN�CONFIGURATION; THISTANK IS 434 <br /> BA <br /> STAND-ALONE TANK <br /> We-W& C cW v4) El 2.ONE IN A COMPARTMENTED VNIT. <br /> Complete one pahe for etcli compartment in the unit. <br /> DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 <br /> l0 -'3^49 1D 17oO 1 <br /> JZ(-,TANKUWANPCONTENTS <br /> TANK USE 2-11a.MOTOR VEHICLE FUELING [I lb.MARINA FUELING 0 Jr.AVIATION FUELING 439 <br /> 0 3.CHEMICAL PRODUCT STORAGE 0 4,HAZARDOUS VVA97E(I.dd.Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL PiSC <br /> [1 6.OTHER GENERATOR FUEL C3 95.UNKNOWN ❑ 99,OTHER(SPeCW 439a <br /> CONTENTS PETROLEUM: [I la-REGULAR UNLEADED r] i.,miDGkADEUNLFADED 21b.PREMIUM UNLEADED 440 <br /> ❑ 1.DIESEL [I 5.JET FUEL El 6.AVIATION GAS <br /> ❑ 8,PETROLEUM BLEND FUEL El 9.OTHER PETROLEUM - (Specify): 44% <br /> NON-PETROLEUM:❑ 7.USED OIL 0 10.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUMS ify): 4406 <br /> IV,.TANK CONSTRUCTION:: <br /> -TYPE OF TANX 0 LSINGLE WALL 5�r2,DOUBLE WALL El 95.UNKNOWN 443 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS 0 6.INTERNAL BLADDER 444 <br /> ❑ 7.STEEL+INTERNAL LINING 0 95.UNKNOWN El 99,OTHER_ (Specify): 44.4& <br /> SECONDARY CONTAINMENT 13 1.STEEL gri.FIBERGLASS 0 6.EXTERIOR MEMBRANE LINER 0 7.JACKETED 445 <br /> [1 90.NONE [1 95,UNKNOWN []99.OTHER(Speoify) 445R <br /> OVERFILL PREVENTION [11.AUDIBLE&VISUAL ALARMS [12.BALL FLOAT ;-a 3.FILL TIME SHUT-OFF VALVE <br /> El 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V.1PROD:UCT WASTE FIFING'CONSTRUCTION- <br /> -2. <br /> PIPING CONSTRUCTION ❑1.SINGLE-WALLED 9 DOIMLE-WALLED [3 99.OTHER 460 <br /> SYSTEM TYPE RT 11 PRESSURE ❑ I.GRAVITY [1 3.CONVENTIONAL SUCTION U 4,SAFE SUCTION(23 CCR§2636(&)(J)J 454 <br /> PRIMARY CONTAINMENT ❑ 1,STEEL 0'4,F75CROLASS [1 8.FLEXIBLE Lj MRIGID PLASTIC 464 <br /> ❑ 90.NONE El 95.UNKNOWN Q 99,OTHER(SP-4): 464a <br /> SECONDARY CONTAINMENT 0 1.STEEL R4.FIBERGLASS 0 8.FLEXIBLE Lj to.RIGID PLASTIC 464b <br /> C) 90.NONE 0 95.UNKNOWN 0 99,OTHER(Specify): 4645 <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE ;g 1.SINGLE WALL [1 2.DOUBLE WALL EI 90.NONE 464d <br /> V1.VENT,:VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING;CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT 16 1.STEEL M4.FIBERGLASS L1 10.RIGID PLASTIC Ll 90.NONE L1 99,OTUR(Specify) 4645 <br /> 464el <br /> VENT SECONDARY CONTAINMENT --'r?4 FIBERGLASS 0 10,RIGID PLASTIC 0 90NONE 99 <br /> .OTHER 0 .OTHER&004) 464f ErI.STEEE 4454fl <br /> VR PRIMARY CONTAINMENT El 1.STEEL ar4-.FIBERGLASS 0 10.RIGID PLASTIC [I go.NONE 0 99,oTmr?(Specify) 4648 <br /> 464 <br /> I--STEEL E 0 9�.OTHER?Spacify) 4641 <br /> VR SECONDARY CONTAINMENT 0 4.FIBERGLASS [3 10.RIGID PLASTIC El 90.NON 464h <br /> VENT PIPING TRANSITION LL [1 2.DOUBLE WALL FMO.NONE 4641. <br /> 4.FIBERGLASS Lj to.RIGID PLASTIC U 90.NONE [:199,OTHER(Specify) 4641 <br /> R)$Eg PRIMARY CONTAINMENT L-r 1,STEEL 464'I <br /> RISER SECONDARY CONTAINMENT 464kJ <br /> L3 1,STEEL [1 4.FIBERGLASS to.RIGID PLASTIC El 90.NONE 0 99,OTHER(Specify) 464k <br /> FILL COMPONENTS INSTALLED @-I.SPILL,BUCKET 23,STRIKER PLAT&BOTTOW'PROTECTOR Lj 4,CONTAINMENT SUMP 45la-c <br /> VIL:UNDER DISPENSER CONTAINMENT(UDC). <br /> CONSTRUCTION TYPE R-1.SINGLE WALL Lj 2.DOUBLY WALL 0 3.NO DISPENSERS El 00.NONE 449a <br /> CONSTRUCTION MATERIAL 1-] 1,STEEL 4_FIBERGLASSEl to.RIGID PLASTIC Lj 99.OTHER(Specify) 449b--c <br /> VAGI(. CORROSION PROTECTION <br /> STEEL. COMPONENT PROTECTION ❑ 1.SACRIFICIAL ANODE(S) [1 4.IMPRESSED CURRENT ❑ 6.ISOLATION 449. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION, I certify tbalthis UST system is compatible with the hazardous substance stored and that the Information provided herein is true,accurate, <br /> and In full ckl9pliance with legal requirements. 470, <br /> APPLICANT SIGNATIIRW/ 1-1-� DATE <br /> APPLICANT NAME(prink/ 471. APPLICANT TITLE 472 <br /> , <br /> J,'66AAj V)o HAJ+ Z2 4-O- <br /> Mt(1212007) <br /> UPCF UST-B-112 <br />