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NIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. Fora JIS7'closure or removal,complele on1j,ibis section and Sections 1,11,IAD" and IX belolt) 430 I[] L NEW PERMIT3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: _ 430. DATE EXISTING UST DISCOVERED: 430h. I. FACILITY INFORMATION PTNE (Agency Use Onlj) F _ O O - 1. E(Same as Facility Name or DBA-Doing Business As) 3. SP- QPM Kis Eti-rEf-P/LISE LLC- E ADDRESS 103 CITY 104 S• MAIN ST( EE7 MkNTF-c.AC_Il. TANK DESCRIPTION 432. TANK MANUFACTURER 433TANK CONFIGURATION:THISTANKIS 434 �1.A STAND-ALONE TANK Complete one page for each '2.ONE IN A COMPARTMENTED UNIT eompumwn in the unit DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437, III. TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Mucks Uaea oil) ❑ 5.EMERGENCY GENERATOR FUEL(HSC§25281.5(01 __ ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 9_9.O_T'HER(Spec 439a. CONTENTS PETROLEUM:i❑ ]a.REGULAR UNLEADED -❑ lc.MIDGRADE UNLEADED �.I b.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL 0 6 AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify)_ 440a . NON-PETROLEUM:❑ 7.USED OIL ❑ 10,ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406. IV. TANK CONSTRUCTION TYPE OF TANK _ _❑ 1.SINGLE_WALLki. .DOUBLE WALL El 95.UNKNOWN 443. ------------------ PRIMARY CONTAINMENT ❑ 1.STEEL_ FIBERGLASS6.INTERNALBLADDER 444. 7_STEEL+IN WING--_._-- Q 95.UNKNOWN ❑ 99.OT_HER_(Specify) 444& SECONDARY CONTAINMENT I.STEEL X3.FIBERGLASS 0 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE _ ❑ 95.UNKNOWN --- ❑99.OTHER�fy)_ 445x, OVERFILL PREVENTION �1.AUDIBLE&VISUAL ALARMS �2.BALL FLOAT 0.3.FILL TUBE SHUT-OFF VALVE 452 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUC_TIO_N _ ]_SINGLE WALL 2.2Q W__A_L_L_❑ 99_OTHER _- _ - -_ - --_-_- - - Mo _ ase. -LiRIMARY STEM TYPE 1.PRESSURE__ ❑ 2.GRAVITY _ ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR 263 a 3 CONTAINMENT D 1 STEEL X4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLA 464, _ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify)_ 464& CONDARY CONTAINMENT ❑ 1.STEEL <4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specs 464c ING/TURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 4640 VI. VENT, VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL '19:4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [199.OTHER(Specify): gykl. VENT SECONDARY CONTAINMENT ❑ i.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): �fj VR PRIMARY CONTAINMENT ❑ L STEEL 719 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464648 VR SECONDARY CONTAINMENT-- ❑ 1_STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC t5 90.NONE ❑ 99.OTHER(Specify): 46µl. ` ----._.... ---------- 4641 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL �.NONE RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464it RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 441. FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATFJBOTTOM PROTECTOR 4.CONTAINNIENT SUMP 45"' VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE !.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE d69e CONSTRUCTION MATERIAL ❑ I.STEEL X4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 44694 VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT vr 6.ISOLATION 448 IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatibie with the hazardous substance stored and that the information prm,ided herein is true, accurate and in full compliance with legal requirements. ��- ;PPLICANT SIGNATURE DATE ')1 La I i O 470 APPLICANT NAME(print) 471. 472 APPLICANT TITLE am `�V-Q L DEeP '"Ai'M &L UPCF UST-B Rev.(12/2007)-1/2 . wew.unidocs.org