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3 UNIFIED PROGRAM CONSOLIDATED FORM ,c1 t/DQ UNDERGROUND STORAGE TANK l ( / OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPEOCTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11,111,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 El 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430- 1 DATE EXISTING UST DISCOVERED: 4308. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) NI -10 10 O - A A1614-1 BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) MA,kN sVLE1 ALC-0 /"QM - IK-JS ENTE0LPk45-E LLL BUSINESS SITE ADDRESS 103 CITY 104. 1100 S• MRIN SrLLt7 MkN"CE�A , LA `A 5`33-7 II. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. .A STAND-ALONE TANK Complete one page for each LJ 2.ONE INA COMPARTMENTED UNIT compartment 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 VF4 a.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439. 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(includes used oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] _ ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439& CONTENTS PETROLEUM: p la.REGULAR UNLEADED la MIDGRADE UNLEADED ❑ ]b.PREMIUM UNLEADED 440• '❑ 3.DIESEL 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL [39.OTHER PETROLEUM(Specify): 440& ---._ - -....-----.........._..---- ..__..._.......--_.....--- NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL K2.DOUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT ❑ L STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 _❑ 7.STEEL+INTERtfV LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444& SECONDARY CONTAINMENT ❑ 1.STEEL )!L3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 44s ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specifyp_ 445a. OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT b`,RILL TUBE SHUT-OFF VALVE 412 4.TANK MEETS REQUIREMENTS FOR-EXEMPTION FROM OVERAlM,PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL DOUBLE WALL ❑ 99.OTHER 460. SYSTEM TYPE I.PRESSURE_rj 2.GRAVITY ❑ 3.CONVENTI.ONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR 2636(a)(3)] 458. PRIMARY CONTAINMENT [1 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE [3l0.RIGID PLASTIC 464. ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(S ): 464a. SECONDARY CONTAINMENT ❑ 1.STEEL 04.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL [12.DOUBLE WALL ❑ 90.NONE 4644. VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 13 ..STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4641. --- VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ��((90.NONE ❑ 99 OTHER(Specify): 464f1 �- -._._.._...__ VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90_NONE [199.OTHER(Specify): 4 ]. --- VR SECONDARY CONTAINMENT [31.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 'W90.NONE ❑ 99.OTHER(Specify): 4664h7 VENT PIPING TRANSITION SUMP TYPE ❑ 1,SINGLE WALL ❑ 2.DOUBLE WALL 'K90.NONE 464` RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4 i. RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 1990.NONE ❑ 99.OTHER(Specify): 4641- FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATEBOTfOM PROTECTOR 4.CONTAINMENT SUMP 451a . VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL -� ❑ 2.DOUBLE WALL [33.NO DISPENSERS El 90.NONE469a CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4699cc. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.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. APPLICANT SIGNATURE DATE M2-'0j'0'6 470 APPLICANT NAME(print) K U L b,EEP S 1 C 1 y) ] APPLICANT TITLE Y'1� � L w 477 UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org