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& M' a UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION- TANK INFORMATION (0-form per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11,111, 11;and LC below) 430 ❑ I.NEW PERMIT 9 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 0 7.UST PERMANENT CLOSURE ON SITE 0 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430- 1 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID h(Agent} Use Onl)) t; _ Q D BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3 MA-1N 9:T9LEE1 A#,C.v MM0 M - KJS EN'TERPk%SE LLC.., BUSINESS SITE ADDRESS 103, 1 CITY 104 1100 S MRtN sr�>rti7 MA-N_fEC.A ( 9 533 II. TANK DESCRIPTION TANK ID k 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 11.A STAND-ALONE TANK Complete ane page for each �_2.ONE IN A COMPARTMENTED UNIT compartmmt 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 a.MOTOR VEHICLE FUELING439 ❑ lb.MARINA FUELING ❑ Ic.AVIATION FUELING JD 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(lodudes Used oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(01 ❑ 6 OTHER GENERATOR FUEL _❑ 95.UNKNOWN ❑ 99.OTHER( 439a. CONTENTS PETROLEUM: C la.REGULAR UNLEADEDic.MIDGRADE UNLEADED ❑ lb-PREMIUM UNLEADED 440. "❑ 3.DIESEL '0'5.JET FUEL ❑ 6.AVIATION GAS _ _ [18.PE_TROLEUMBLEND_FUEL__❑ 9.OTHER PETROLEUM(Specify): 44W - NON-PET_ROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUMS ): 440b. IV. TANK CONSTRUCTION TYPE.OF TANK - - ----�_1.SING WALL 2.DOUBLE WALL _0 95_UNKNOWN -------- ------ ._...._.___..-----------_...-__-- 443 PRIMARY CONTAINMENT ❑ L STEEL 3.FIBERGLASS _- ❑ 6.INTERNAL BLADDER 444 ---._-- - - - ----0 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN [1 99.OTHER(Specify): 444x. SECONDARY CONTAINMENT ❑ 1.STEEL FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER 0 7-JACKETED 445. -- --------- [1 90.90.N_ONE ❑ 95.UNKNOWN _❑99.OTHER(Spea445s, r __--_ iV, OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS �2.BALL FLOAT S RILL TUBE SHUT-OFF VALVE 14.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT 452. V. PRODUCT/WASTE PIPING CONSTRUCTION �]N�G7STR_U_CTIO_N ❑ I.SINGLE WALL .DOUBLE WALL _❑ 99.OTHER _ 460' _SYSTEM TYPE _ 1.PRESSURE 2.GRAVITY ❑ 3.CONVENTIONAL_SUCTION-0 4 SAFE SUCTION[23 CCR 4 laX_�_y 458. ---.----------- PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS [38.FLEXIBLE ❑ 10.R1GiD PLASTIC 464. ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify)_ 464a SECONDARY CONTAINMENT ❑ I.STEEL 04.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. _ _❑ [190.NONE _ 95.UNKNOWN 1399.OTHER(Specify): - PIPING/fURBINE CONTAINMENT SUMP TYPE - 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI. VENT, VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT L7 :.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE _❑ 99.OTHER(Specify): 46 e1. 464f. VENT SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 46411. VR PRIMARY CONTAINMENT -- ❑ 1.STEEL - 4 FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify), q(�8. � IT VR SECONDARY CONTAINMENT ❑ 1.STEEL. ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ VENT PIPING TRANSITION SUMP TYPE -- -�--_---- 99.OTHER(Specify): 464hl. ------_-- ----- 464❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL DK90.NONE - -- RISER PRIMARY CONTAINMENT %1.STEEL ❑ 4.FIBERGLASS [1I0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464j, RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): creak FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLAT0B0TT0M PROTECTOR 4.CONTAINMENT SUMP 451- V11. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE- 1.SINGLE WALL _ 0 2.DOUBLE WALL ❑ 3.NO DISPENSERS _90.NONE 4'9a ----- _. - - _.__. -. . ----- ----- ---- _---- 4696. CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION [12.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448 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, accurate,and in full compliance with legal requirements, 470, +. 7PPLICANT SIGNATURE- �= DATE >'Z,f,I (p tt 472. APPLICANT NAME(print) Vv LACE P C- SN Ark A- APPLICANT TITLE M EM�,E2 i�L L UPCF UST-B Rev.(12/2007)-111 wwR.unidocs.org