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Mk Wr UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,II,Ill,IV,and IX below) 430 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 0 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430' DATE EXISTING UST DISCOVERED: 430b L.;'FACILTIT INFORMATION FACILITY ID#(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Bursium As) BUSINESS SITE " , s CTf1 uoa II.TANKDESCRIPTION'. TANK 0# 432 TANK MANUFACTURER Q TANK CONFIGURATION:THIS TANK IS 434 ® ,S 7/ 1 ^ ❑1.A STAND-ALONE TANK ❑2.ONE IN A COMPARTMENTED UNCI. C-Ulele oratoreadiPARTMENv�tlas omt DNFE UST SYSTEM INST�LLEll 435 TANK CAPACITY I ALLONS 4 NUMBER OF COMTS IN THE UNIT 437 III:`TITK SSE AMVCONTENTS TANK USEM.MOTOR VEHICLE FUELING [31b.MARINA FUELING ❑ lc.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(ladudea Used 011) ❑5.EMERGENCY GENERATOR FUEL[ASC i25281.5(c)) ❑ &OTHER GENERATOR FUEL ❑ 95.UNKNOWN Tl 99.OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ la MIDGRADE UNLEADED ,Jb.PREMIUM UNLEADED 44o aj'DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 11.OTHER NON-PUTROLEUM 440b IV.;TANK:CQIITSTRUCTION TYPE OF TANK 1.SINGLE WALL DOUBLE WALL g 95.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL U 3.FIBERGLASS E3 6.INTERNAL BLADDER 444 7.STEEL+INTERNAL LINING ❑95.UNKNOWN ❑99.OTHER S 444a SECONDARY CONTAINMENT ❑ I.STEEL W.FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER 7.JACKETED 445 ❑ 90.NONE ❑95.UNKNOWN ❑99.OTHER 445a OVERFILL PREVENTION L AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. ❑4.TANK MEETS MUMMAENTS FOR EXEMMON FROM OVERFELL REVENTION EQUIPMENT V PROAITCT f WAM-PIPING CONS`RIJCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED 2.DOUBL&WALLED ❑99.OTHER 460 SYSTEM TYPE .PRESSURE ❑2.GRAVffY ❑3.CONVENTIONAL SUCTION 4.SAFE SUCTION 23 CCR§XWa)(3) 42 PRIMARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS S.FLEXIBLE ❑ 10.RIGIDPLASTIC 464 ❑90.NONE ❑ 95.UNKNOWN 99.OTHER(Specify): 464a SECONDARY CONTAINMENT 13 1.STEEL ❑4.FIBERGLASS WS.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 [39o.NONE ❑95.UNKNOWN ❑99.OTHER(Specify): 464c PIPINGn`URBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL W2.DOUBLE WALL ❑90.NONE 4644 VI:VEN3`,VAPORREOV'ERT'( } 0IfRi$F1 /FIL.Y,:pIPE;PIPING CONSTRUCTiON VENT PRIMARY CONTAINMENT U 1.STEEL F,4.FIBERGLASS I0.RIGIDPLASTIC 0 90.NONE 0 99.OTHER(Specify) 4640 VENT SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) �f VR PRIMARY CONTAINMENTI.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 464ft 90.NONE 99.OTHER(Specify) 464. VR SECONDARY CONTAINMENT I.STEEL 464 1 ❑ 4.FIBERGLASS l0.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464h VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WAi L NONE Ch1 4641 RISER PRIMARY CONTAINMENT L STEEL Ej 4.FIBERGLASS U 10.RIGID PLASTIC 13 90.NONE 13 99.OTHER(Specify) 464j RISER SECONDARY CONTAINMENT 1.STEEL fik4.FIBERGLASS10.RIGID PLASTIC 90.NONE 99.077IER(Specify) 4641 4Mk FILL COMPONENTS INSTALLED U 1.SPILL BUCKET 3.STRIKER PLATEBOTTOM PROTECTOR 4.CONTAINMENT SUMP 451 yQ.UNDER'DMPENSER CONTAINMENT((TpC), CONSTRUCTION TYPE 1.SINGLE WALL ❑2.DOUBLE WALL ❑3.NO DISPENSERS ❑90.NONE 469a CONSTRUCTION MATERIAL 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 99.OTHER(S ) 469b-c _;. . VIII« CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑2.SACRIFICIAL ANODE(S) ❑4.Bd WMED CURRENT aKISOIATION PC APPLICANT SIGNATURE CERTIFICATION:I certify that this UST system is compatible with the hazardous substance stored and that the Information provided herein is true,ateurafe, and it full comp with legal requirements. 4 APPLICANT SIGNATURE l� DATE �J ago. APPLICANT NAME 471• _ APPLICANT TITLE 472.UPCF UST-11-1/2 Rev.(12/2007)