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6% <br /> MPMED PROGRAM CONSOLIDATED FO. -. <br /> UNDERGROUND STORAGE TANK o, <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) <br /> TYPE OF ACTION (Check one item only. Fora ST closure or remava4 complete only this section and Sections I,II,III,IV,and IX below) 430. <br /> ❑ 1.NEW PERMIT M3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430& 1 DATE EXISTING UST DISCOVERED: 430b. <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) --j 4 6 � 1 <br /> 15161 -1010101-1 <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> MhtN S19-EET NCV M - 3SILS ENTERPI�ts�s II�UL <br /> BUSINESS SITE ADDRESS 103 CITY 104. <br /> ( loo S. MNt N STPIP-ET M A-N TEC.A t.A- 4 533 q <br /> II. TANK DESCRIPTION <br /> TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. <br /> 1.A STAND-ALONE TANK Complete one page for each <br /> MIT) G KA&F- t]-2.ONE IN A COMPARTMENTED UNIT compartment in the unit. <br /> DATE UST SYSTEM INSTALLED 435, TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. <br /> 104 11, 600 - <br /> III. TANK USE AND CONTENTS <br /> TANK USE la MOTOR VEHICLE FUELING ❑ ib.MARINA FUELING ❑ lc.AVIATION FUELING 439- <br /> 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)I <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439& <br /> CONTENTS PETROLEUM: ❑ la REGULAR UNLEADED IX 1c.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440. <br /> ❑ 3.DIESEL T3 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440x. <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUMS ): 440b. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL jjL3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444& <br /> SECONDARY CONTAINMENT ❑ 1.STEEL W.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. <br /> ❑ 90.NONE 95.UNKNOWN [199.OTHER(Specify): 445a. <br /> OVERFILL PREVENTION I.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. <br /> 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING_CONSTRUCTION ❑ 1.SINGLE WALL2.DOUBLE WALL ❑ 99.OTHER 460. <br /> SYSTEM TYPE 1.PRESSURE 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR§2636(.x3)] 458. <br /> PRIMARY CONTAINMENT 1.STEEL4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. <br /> ❑ 90.NONE 16 95.UNKNOWN ❑ 99.OTHER(Specify): 464& <br /> SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. <br /> ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d. <br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC [190.NONE ❑ 99.OTHER(Specify): 4� <br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC X 90.NONE ❑ 99.OTHER(Specify): 464) <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC [190.NONE [399.OTHER(Specify): 46644& <br /> E <br /> VR SECONDARY CONTAINMENT [11.STEEL ❑ 4.FIBERGLASS [110.RIGID PLASTIC 90.NONE [199.OTHER(Specify): a64hhl. <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 464` <br /> j. <br /> RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC [:190.NONE ❑ 99..OTHER(Specify): 464 <br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL [14.FIBERGLASS [I10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 4Mkl. <br /> FILL COMPONENTS INSTALLED1.SPILL BUCKET3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 451a-c. <br /> VII. UNDER DISPENSER CONTAINMENT (UDC) <br /> CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469& <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL 54 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 699sc. <br /> VIII. CORROSION PROTECTION <br /> a <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES ❑ 4. NTRESSED CURRENT 6.ISOLA DON 448. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, <br /> accurate,and in full com liance with legal requirements. <br /> APPLICANT SIGNATURE DATE rL q 2 511 t azo. <br /> APPLICANT NAME(print) ([�11L��n C SH F ► (� 471 APPLICANT TITLE a 472. <br /> UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org <br />