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fl UTFnED PROGRAM CONSOLIDATED F010W. 3 UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. Fora ST closure or removal,complete only this section and Sections 1,11,Ill,IV,and IX below) 430. ❑ 1,NEW PERMIT3.RENEWAL PERMIT [15.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430s DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use only) IFIAI-101olol-1114-16141 1. BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. MA%t A STREET ALLO Al APM -- JSK.S EUTE"ILUE-L , INC- BUSINESS SITE ADDRESS 103. 1 CITY 104. lloo • MA%N STPLEE1 MANTELA, LA 9331`6 II. TANK DESCRIPTION TANK ID# -( Q 9 a3z. TANK MANUFACTURER 433. LJ CONFIGURATION:THIS TANK IS 434, M1 n t7 A Dom+ �[ G 19 nL A STAND-ALONE TANK Complete one page for each ►/ I<A . I, F, 7 2.ONE IN A COMPARTMENTED UNIT compartment in the unit. DATE UST SYSTEV INSTALLED 435• TANK CAPACITY IN GALLONS 436• NUMBER OF COMPARTMENTS IN THE UNIT 437• )qdn 01 l'l. 001D M. TANK USE AND CONTENTS TANK USE 1 a.MOTOR VEHICLE FUELING ❑ 1 b.MARINA FUELING ❑ 1 c.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): 439L CONTENTS PETROLEUM: ❑ I a.REGULAR UNLEADED 1 c.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440• 1 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS __ ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify: 440L _ NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 1K 2.DOUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7_STEEL+INTERNAL LIMNG ❑ 95.UNKNOWN ❑ 99.OTHER(Specifyj. 444L .... SECONDARY CONTAINMENT ❑ I.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER [17.JACKETED _445. _ [190.NONE_ 95.UNKNOWN [399.OTHER(Specify): 445L OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT [13.FILL TUBE SHUT-OFF VALVE a5a. 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE' 2.DOUBLE WALL ❑ 99.OTHER _ _ T6 70- SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY -^❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR 263 a(3) 458. PRIMARY CONTAINMENT ❑ 1.STEEL4.FIBERGLASS 138.FLEXIBLE ❑ 10.RIGID PLASTIC 464. 1190.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464a. SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. PIPING/TURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d. VI. VENT,VAPOR RECOVERY(VR) AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL %4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464el. VENT SECONDARY CONTAINMENT ❑ 1.STEEL Ll 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE [199.OTHER(Specify): 464fj: VR PRIMARY CONTAINMENT ❑ 1.STEEL 9 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4644 s. VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 9 90.NONE ❑ 99.OTHER(Specify): 4664hi. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 4641• RISER PRIMARY CONTAINMENT A].STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46q j: RISER SECONDARY CONTAINMENT El I.STEEL [14.FIBERGLASS [110.RIGID PLASTIC - 90.NONE ❑ 99.OTHER(Specify): 464gj FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 451a-c. VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE _ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469x. CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448. DL 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. 0. APPLICANT SIGNATURE `� DATE 1 Z� ` 47Z APPLICANT NAME(prim) ��` �� G. S H a�M A 471 APPLICANT TITLE F.0 472.