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1 <br /> May 1109 03:46p MVP Petroleum Engineering 916-984-1117 p.3 <br /> (A 102,14111 ko <br /> UNiFCED PROGRAMCONSOL>IDATED FORM- <br /> UNDERGROUND xy J`UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) <br /> TYPE OF ACTON (Check one item only, For a UST cost re or removal,complete only this section and Sections 1,,11.Ill,l6'and IX belota) 430. <br /> ❑ <br /> ].NEW PERMIT ❑ 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION <br /> 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL <br /> DATE UST PERMAN'HNTLY CLOSED: 4304 DATE EXISTTNG UST DISCOVERED: 4301 <br /> I. FACILITY INFORMATION <br /> FACILITY 10 9(Agency Use On4q _ 1 <br /> BUSINESS NAME,rS7we as Foci NY Name or D6.4-Doing Business As) 5. <br /> BUSINESS SITE ADDRESS ro; , CITY 104. <br /> II. TANK DESCRIPTION <br /> TANK ID i> 432. TANK MANUFACTURER 433- TANK CONFIGURATION:THIS TANK IS 434. <br /> TAI Of �O I.A STAND-ALONE TANK Co plCie one page for each <br /> vv v L`rN 2.ONE IN A COMPARTMENTED UNIT compum III m The uroe <br /> DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436• NUMBER OF COMPARTMENTS IN THE.UNIT 437. <br /> d d <br /> III. YANK USE AND CONTENTS <br /> TANK USE ® ia MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439. <br /> 0 J.CHEMICAL PRODUCT STORAGE E34.HAZARDOUS WASTE IbdudesUsed o;0 Q 5.EMERGENCYGENERATOR FUEL Imcg252sys(e)) <br /> 6.O- ER GENERATOR FUEL _❑ 95.UNKNOWN ❑ 99.OTHER(Spccifyl: 4391 <br /> ------- PETROLEUM: ---•-----__..-._...-.----- --------- ----- -----..--- --- -- �..FMI -N- - <br /> CONTENTS PETR.OLEUNM: la.REGULAR UNLEADED ❑ tc MIDGRADE UNLEADED ❑ ib.PREMIUM UNLEADED �- <br /> 3-DIESEL ❑ 5.JFr FUEL ❑ 6.AVLATION GAS <br /> ........__.. -..0_8.PETROLEUM BLEND FUEL [] 9.017iER PETROLEUM(Specify)_- .40a <br /> .. <br /> NON-PETROLEUM:[37.USF.DOIL !0.CTFIANOL <br /> ❑ 11.OTHER NO`-11SIROLEUM(Specify): 4401:. <br /> IV. TANK CONSTRUCTION <br /> -TYPL OF TANK_ ---- ❑ i.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443. <br /> PRI YLARY CONTAINMENT 1 STEEL - ❑ 3.FIBERGLASS- ❑ 6 INTERNAL BLADDER - 444. <br /> STEEL+rNTERNAL LINING-- -- -_0 95 UNKNOWN [1 99.OTHER(Specify). 444a. <br /> SECONDARY CONTAINR4ENT ❑ L STEELL 3.FIBERGLASS ❑ 6_Eh'TERIOR MEMBR4NE LINER ❑7.IACKETED 443 <br /> NONE ❑ 95.UNKNOWN 0 99.OTHER(S�ecify) :451 <br /> OVERFILL PREVENTION t.AUDIBLE&VISUAL ALMMIS [12.BALL FLOAT 3.FILL TUBE S!1UT-0FF VALVE 45= <br /> 4.TANK MEETS R UL'tEMENT'S FOR EXEMPTION FROM OVERFILL PREVENTION E UIPMEN'T <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑_I.S[N`GLE WA]-L 2.DOUBLE WALL ❑ 99.OTHER 460. <br /> --- - ----- -----'--------- -- -- - .__._....-- <br /> SYSTEM TYPE _._ 1.PRESSURE ❑ p GRAVITY _❑ 3.CONVENTIONAL_SUCT_I_ON ❑ 4.SAFE SUCTION 123CCRS2S36(a)(3); 45s_ <br /> PRIMARY CONTAENA9ENT ❑ 1.STEEL �4.FIBERGLASS C] 8.FLEXIBLE ❑ I0.RIGID PLASTIC 464. <br /> 090. <br /> NONE95.U_NKNO_W_N_ ❑ 99.OTHER 4 <br /> _ER(Speciryy 46 <br /> SECONDARY CONTAINMENT ❑ L STEEL PL4.FIBERGLASS �❑ FLEXIBLE EXIBLE ❑ 10.R1GID PLASTIC -464b <br /> ❑ 90.NONE ❑ 91.UNKNOWN----0 99.OTHER(Sped,. )_ 464E <br /> PTPING/TURBINE CONTAINMENT SUMP TYPE I.SINGLE PJALL ❑ ?.D6U8LL-WALL ❑ 90.NONE 4Wd. <br /> VI. VENT, VAPOR RECOVERY (VR)AND RISER I FILL PIPE PIPING CONSTRUCTION 411 <br /> I VENTPRIMARY CONTAINMENT ❑ 1.STEEL IV 4.FIBERGLASS ❑ 10.RIG ID PLASTIC ❑ 90.NONE [j99.OTHER(Specify): q j <br /> _. _.- _..--- --- .- .--- - - ---- -. .. - ----- -.._v. ---- -- <br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC90.NONE ❑ 99.OTHER(Specifv): 6w4n. <br /> _ an. <br /> V R PRIMARY CONTAINMENT ❑ 1.STEEL IR 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Spedfv): 4tL <br /> VR SECONDARY CONTAINMENT ❑ 1 STEEL ❑ 4,T1BERGLASS ❑ 10 RIGID PLASTIC 9 <br /> 0_NONE E] OTHE 99.OTHER(Specify): 4b hl <br /> _ .... - <br /> VENT PIPING TRANSITION SUMP TYPE _- ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL tZ90.NOME 464` <br /> RISER PRIMARY CONTAINMENT 1.STEEL ❑ 3.FIBERGLASS ❑ 10.RIGID PLASTIC Q 90.NONE [194.OTHER(Specify): 464j. <br /> fy): 46ii1 <br /> _RISER SECONDARY_CONTAINMEN[T ❑ I.STEEL ❑ 4.FIBERGLASS - ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 199.OTHER(Specify): 44,64k. <br /> FILL COMPONENTS INSTALLED­--g <br /> I.SPILL BUCKET P1 3.STRIKER PLATE%BOTTO.V PROTECTOR ❑4i CONTAINNIENT SUMP 451a-c, <br /> VII. UNDER DISPENSER CONTAIMUENT(UDC) <br /> CONSTRUCTION TYPL 1.SINGLE WALL - iG9i <br /> - -.._.,_.._.. ....---.-- .-__...------ -__.--_-. 2_DOUBLhLYALL - 3 NODISPE"fSERS_. ❑ 9'-V '.. - <br /> CONSTRUCTION MATERIAL ❑ I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99,OTFIER(Specify) °q <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENTPROTECTTON ❑ 2_SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6)ISOLATION 445. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION:1 certify that this UST systcm is compatible with the hazardous substance stored and that the information provided herein is true, <br /> accurateAnd in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 470. <br /> APPLICANTNAME(print) 471' APPLICANi'TITLE 47 i <br /> UPCF UST-0 Rev.(122007)-112 wivw.unidocs org <br />