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Amok OL l011-1 <br /> IFIED PROGRAM CONSOLIDATED F <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) <br /> TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections I,H,III,IV,and IX below) 430. <br /> ❑ 1.NEW PERMIT3.RENEWAL PERMIT [15.CHANGE OF INFORMATION <br /> [36.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 430b. <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) F I A 1 -10 1 o 1 o - -114-16 4 l <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3 <br /> (AA%" STLEET &P-LO WPM JS. KS EN"[E0-PA4(,E.S INC, <br /> BUSINESS SITE ADDRESS to3. Cly toa. <br /> 1100 G'19-E E T SAA t <br /> II. TANK DESCRIPTION <br /> TANK ID# a32. TANK�/MAtNAUF,�A/CTURER a33. TANK CONFIGURATION:THIS TANK IS 434. <br /> ISE N1�U M U 1�1 LE OE /�lr F�1�E S 1.A STAND-ALONE TANK Complete one page for each <br /> 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 /> III. TANK USE AND CONTENTS <br /> TANK USE la MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439. <br /> CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Inchdes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSc§25281.5(c)] <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439x. <br /> CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ 1 c.MIDGRADE UNLEADED l b.PRaaum UNLEADED 440. <br /> ❑ 3.DIESEL ❑ 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 /> ❑ <br /> 11.OTHER NON-PETROLEUM(Specify): 440b. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. <br /> ❑ 7.STEEL+ AL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444x. <br /> SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445x. <br /> OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS X 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 WALL 2.DOUBLE WALL ❑ 99.OTHER 460. <br /> SYSTEM TYPE XI.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR§2636(ax3)) 459. <br /> PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. <br /> ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464x. <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 4644. <br /> VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL K4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4 4ej; <br /> VENT SECONDARY CONTAINMENT [11.STEEL El 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE El99.OTHER(Specify): 464L <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL 15C4.FIBERGLASS [110.RIGID PLASTIC ❑ 90.NONE C199.OTHER(Specify): 4644gL <br /> VR SECONDARY CONTAINMENT E] 1.STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC 1990.NONE [199.OTHER(Specify): 4664hi. <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 464i. <br /> RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ lo.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46a j, <br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS [1l0.RIGID PLASTIC 90.NONE [199.OTHER(Specify): 464k1. <br /> FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATEBOTTOM PROTECTOR 4.CONTAINMENT SUMP 45la-c. <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a. <br /> CONSTRUCTION MATERIAL ❑ I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 46g� <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES ❑ 4.IMPRESSED CURRENT 6.ISOLATIft J 448. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the informatovidcd herein is true, <br /> accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE470. <br /> 2 2y 1 i <br /> APPLICANT NAME(print) VL)' CEP C - S i-i�M p,471 APPLICANT TITLE � � 472. <br /> UPCF UST-B Rev.(12/200')-1/2 -�''y"• www.unidocs.org <br />