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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form pea Us-r) TYPE;L,WP N (Check one item only. For an UST permanent closure or removal,complete only Ibis section and Sections I,Il,III,IV,and IX below) 430 ❑ 1.NMIT ® 3.RENEWAL FER.Wl' ❑ S.CHANGE Of WORMATION 6.TEMPORARY UST CLOSURE 7.LIST PFRMANFNT CLOS;TR£ON SITE ❑ S.UST REMOVAL DATE UST PERMANENTLY CI.OSF,D- 43c4 DATE"EXISTING USTDISCOVERED: 4.110h I : :ftiC1#!'I'�?V.:.11rs.ORMAT1'0;1�.:: :..::.: :`:::: .. FACILITY ID n(Agency ILte Only) 1 17 _ _ BUSINESS NAME Same as FACTI. T'Y NAME or DBA-Doing Business As) 1 Tv's PEA-V6 Inc- 91115 -7G BUUNN ,58 SITE ADDRESS� � • 101 CITY L4�! 104 ]LT. TANK ID N ,� 432 TANK MANIJFACTTJRF,R -433 TANK CONFIGURATION: 'rens TANK Is 434 �2 A ! A STAND-AI,UNF''rAN1( L� Coe01\=IN A COMPAR,rmwi-bo UNn', ton wA C IN&4+rq wPwt in th4 uriat. [DATF,�,AINSTALLED 4i5 rAN i PACI'1"Y IN LLON5 436 NI IMRF,R OF COMPARTMl I'S 1N THE UNIT 437 I.TAIP+EK;LJ'SE A1NI?`C;:ON'FLN.`f'S.:::. ANK USE ��'[s MO1OR vtruCt.1.FUIiT•INO ❑ Ih.MARINA F(JiO.ING ❑ le.AVIATION h'UEL1N6 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑4.HAZARDOUS WASTE(Inclu&-%vx d()i I) Q S.EMERGENCY GENERATOR FUEL JIISC 425261.5(c)1 ❑ 6.OTITFR GF,NERATOR FUEL ❑ 95.UNKNOWN i' 41% CONTENTS PETROLEL'M: ❑ I�RECUI.Ak UNLEADED ❑ 1e.MIDGRADE UNLEADED b.PREM[t759 UN'LEADE 440 ❑ 3.DIESEL ❑ 5.)ET FUEL ❑ S.1'EIROLEUM BLEND FUEL ❑ 9.O']21ER 1'E 1'ROLEUM (S fy): 440' NON-PETROLEUM: 7.USED OIL ❑ io.FrHA.NOL 11.OTHER NON-PrTRO1.FUM(SpedfX): 440b .. PANIC CANS I'RU:CTIO:N:. :, 'IYPt..:Of TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 44s PRIMARY CONTAINMENT ❑ I.STtiul, )a"3.FIBERCLASS ❑ 6.INTERNAL ULADD17R 444 ❑ 7.STEFI;+TNTFRNAI.T.INING ❑ 95.UNKNOWN Zj 99.OTITER (Soccify): 4445 St•:CON1)ARY CONTAINMENT ❑ I.STEEL WS.FIBERGLASS p 6.1Xn;R1OR MEMBRANE LINER p 7.JACKETED 445 ❑90.NONE ❑ 95,UNKNOWN ©99.OTHER ti cifv): -4454 OVERFILL PREVENTION r3L1.AUDIBLE&VISUAL ALARMS W 2.BALL FLOAT Lj 3.FILL TUBE SHUT-OFF VALVE 452, 4.TANK MEETS RF,QUiRFMF..NI$POR raFMVI'ION PROM OVFRFIt,I.PRt:wr MoN EQUIPMENT V...:P tODUCI'-Y WAS'ITE:IPTKNG.CON S"I'.IttlC1'iON.' _ PIPING [11.SINGLE-WALLED 2.1)OUBLJrWALL£D ❑99.01HER 4(0 SYSTEM TYPE XL 1"PRESSURE ❑ 2 GRAVITY ❑ 3.(Y)NVENTIONAL.SUCnON ❑ 4.SAFE SUCTION r23 CCR 42636(.x3)1 459 PRIMARY CONTAINMGNT ❑ 1.STEEL 4.FTI3GRCI,ASS ❑ 8.1LU(IBIA ❑ 10.RIGIDPLASTIC 464 ❑90.NONR ❑ 95.UNKNOWN (] 99.OTHEI((SP'Xary): 4444 SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑90.NONE 95.UNKNOWN ❑ 99.0T1117R(Specify): 4(A, PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL Q 2.1)01,!81,1,WALL ❑ 90.NONE 4644 VI.VE:M;1,i!APD.R.RECOIVERRY.(V:R).)kND IUSER::7.FII L PIPE PIPINC iICONS'fI'iUCTION .. VITNT PRIMARY(':ONTAINMrNT ❑ 1.STGrI• ,. 4.FI5L'R(;LASS 10.RIGID 11AS'11C Lj 90.NONE El99.OTHER(Specify) 4M4 464e1 VFn rSr,.CONDARYCONTAINMENT ❑ 1.STEEL, EO 4.FIBURCI.As3 0 i0.RIGA)PLAUS11C W.NONE. Q 99.(n'III;R(SPwify) 4R4r 46411 VR PRIMARY CONTAINMENT p 1.STEEL 4.FIBERGLASS p 10.RTGID PLASTIC ❑ 90.NONE Lj 99.OTHER(Specify) 4648 VR SECONDARY CONTAINMENT ❑ 1.STr.I, C FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.O'T'HER(Specify) 464h 4(Ah, VENT PIPINC.'IRAN$rnON$(iMP'rYPF ❑ 1.$INCf,E WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464i. RTSFR PRIMARY CONTATNIvENT ❑ 1.STEEL U 4.rI3 RGI,A,SS 10.RIGID PIAS n(.: ❑ 90,NONF ❑ 99.OTIIFR(Specify) 464, 464'1 RISER SECONDARY CUNTAINMLNT ❑ i..S,'TLGI, 4 El 4.FIBERGLASS 10.RIGID I'LAS'1'lC ❑ 70.NONE ❑ 99.OTHER(Spwify) 464k 46E 1 FILL COMPONENTS INSTALLED I.SPITS.BUCk r ❑3.STRIKER PLATEMOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451M ...... .......... .......... . _ '.:''C�IL:UN:DER;;D�"SPRN:SER:COiV'TAlN1VIENT U ,. E � CONSTRUCTION TYPE ❑ 1.SINGLE WALL 2.DOIMLE WALL [] 3,NU DISPL'NSIiRti ❑ 90.NONE 46% (:ONSTRUCTION MATFRTAL ❑ E.STT T;I.. K4.FIBERC;LASS ❑ 10.RIGID I'LAS11C ❑ 09.OTHER(Specify) 4 c TT.:.COR-R .... VI OSTON PROTECTION STFEI.COMPONF.NTPROTF.CTION p 2SACRIFICIALANODr(s) '❑ 4.IMPRESSEDC:l1RRENT ❑ 6.ISOLATION 44&" .13L APP PPL S1GNATU;RE, CERTIFICATION: I cerci that th' UST s stem is compatible With the ha�ardoas substance stored and that the informati certify y P qn provided herein is true,ace¢tete+r Sind in full ceWpljancwith legal requirements. APPLICANT SIGNATURE T)ATF, 1 y+ w APPLICANT NAME(print) '71' APPLICAN TITLE; iJPCF IJS'T-B-12 Rev.(1212007) ZZO/ S00'd 5L90# 6Z:90 9002/ZZ/LO