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. o jVW UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,IT,III.IV,and TX below) 430 ❑ I.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: a"' I DATE EXISTING UST DISCOVERED: 43[m _ 1. FACILITY INFORMATION FACILITY ID ft(Agency Use Ontt) _ I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 _s-v g-457 BUSINESS SITE ADDRESS 1113 CITYaN 130 S. Srn�L A- Sro 11.TANK DESCRIPTION TANK TD k 3 472 TANK MANUFACTURER 433 TA CONFIGURATION: THIS TANK IS 43i4 CTI,A STAWALONETANK o et 'E IN a tore acPA�ME�ED i in UNIT. DATE UST SYSTEM INSTALLED 435 'TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 4n d 12- cvo VV III.TANK USE AND CONTENTS TANK USE OC la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTF(lmlwfestJscd Oil) ❑ 5.EMERGENCY GENERATOR FUEL IHSC 4'-s.+L5(cll ❑ 6 OTHER QFNERATOR FUEL ❑ 95.UNKNOWN ❑99,OTHER(Spcciry): 43`b CONTENTS PEI ROLEUNI: 1a.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED Ib. EMIUM UNLEADED 4111 0PR 3.DItSEL ❑ S.JET FUEL ❑6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (S if y): 44(x4 NON-?ETROLEUNI:❑ 7.USED OIL ❑ I0.ETHANOL ❑ 1(.OTHER NON-PETROLEUM(Specify): 441b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE LVALL 5 2.DOUBLE WALL ❑ 95.UNKNOWN 447 PRINT ARY CON'rAlNMENT ❑ 1.STEEL PC 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 _ ❑ 7,STEEL 4INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OT1ER (Specir): 4440 SFCONDARYCONTAtNMENT ❑ 1.STEEL K3.FIBERGLASS ❑ 6.EXTERIOR MaIBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.07HER(Specify): 4450 OVERFILL I'REvENI'ION 1.AUDIBLE&VISUAL ALARIMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 45'-. {.TANK MEETS REOUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ I SINGLE-WALLED X2.DOUBLE-WALLED ❑99.OTHER 4114) SYSTEM TYPE ES 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 1=3 CCR¢26?(4mU)I 4As PRIMARY CONTAINMENT ❑ 1.STEEL N -1.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specirv): 444a SECONDARY CONTAINNIFNT ❑ I.STEEL CK 4.FIBERGLASS ❑ a.FLEXIBLE ❑ IO,RIGIDPLASTICW 4rw ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Spociry): 464, PIPINGITURBINE CONTA1NNIEN'F SUMPTYPE El 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.\ONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT C1 1.STEEL Cff 4_FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) s+r 4t.1e1 VENTSECONDARY CONTAINMENT ❑ 1.STEEL g.j.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE U 99.OTHER(Specify) 464r 4641.1 VR PRIMARY CONTAINMENT ❑ I.STEEL 0 4.FIBERGLASS Ll 10.RIGID PLAST15 ❑ 90.NONE 0 99.OTHER(Specify) 4)a` J6.1 1 VR SECONDARY CONTAINNIENT ❑ 1.STEEL 19 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 469. 464hI VENT PI PING TRANSITIONSUNIPTYPE ❑ 1.SINGLE WALL OL2.DOUBLE WALL ❑ 90.NONE 04, RISER PRIMARY CONT:\INNIEN7 Lj 1.STEEL A 4.FIBERGLASS ❑ 10.RIGID PLASTIC I' 90.NONE ❑ 99.OTHER(Specify) 44) 46f1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL 06.FIBERGLASS 10.RIGID PLASTIC 0 90.NONE 99,OTHER(Specify) 4r,4L 4641 FILL COMPONENTS IP45TALLED I.SPILL BUCKET 3.STRIKER PLATE/80TTON1 PROTECTOR 4.CONTAINMENT SUMP 45125 VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUC-TION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑90.NONE 4N4 CONSTRUCTION MATERIAL ❑ 1.STEEL IR 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.01THER(S ifi') 41i111 Vlll. CORROSION PROTECTION STEEL COMPONENT PROTECTION 2. ACRIFLCIALANODE(S) ❑ 4.IMPRESS ED CURRENT ❑ 6.ISOLATION 444. 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,3ccunite, and in full com liance with legal requirements APPLICANTSIGNATURE f 1 DATEOt' 471 1244-� !� _ 01 APPLICANT NAME(print) 471' APPLICANT TITLE �G+�l2t N� fPlr MA74"n -r aW - �. IIPCF usT-B-V2 ars.(L vaao� 9•d LW-99th-60Z lgDM 80U8JMBj d6tb.90 60 2 Def