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IFIED PROGRAM CONSOLIDATED F ,n UNDERGROUND STORAGE TANK Q Qne4 / 7.01I n V�C OPERATING PERMIT APPLICATION-TANK INFO ' RM��Ll V (One form per UST TYP70FACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 430❑ MIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ ARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 410a DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) I BUSINES NAME(Same as FACILITY NAME or DBA-Doing Business As) e� 3 U 1 NESS S TE ADDRESS L 103 CITY{ ,f 104 IL TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 /�*L �� w ,,S n 1.A STAND-ALONE TANK L) O � C�RaJI�'6 2.ONE IN A COMPARTMENTED UNIT. Complete one page for each compartment in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 IH.TANK TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ ]b.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25291.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN K 99.OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED Ib.PREMIUM UNLEA ED 440 IV 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL Le 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL a 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE f 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT 1$ 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED 9 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY X 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458 PRIMARY CONTAINMENT Po 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL ;J 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE 19 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPINGCONSTRUCTION VENT PRIMARY CONTAINMENT P9 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC N 90.NONE 0 99.OTHER(Specify) 464f 464fl VR PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 464g 464 I VR SECONDARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE CY 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ?.SINGLE WALL ❑ 2.DOUBLE WALL 9 90.NONE 4641. RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 464j 464't RISER SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 451a-c VII.UNDER DISPENSER CON NT'(UDC)I.' WP'CONSTRUCTION TYPE ❑ 1.SINGLE WALL .DOUBLE WALL fL 3.NO DISPENSERS ❑ 90.NONE F ;4, 469a CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS- ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) v.369b-c I. CGRROSION PROTECTION ° STEEL COMPONENT PROTECTION _jj_4.SAC CIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION s. I K. APPLICANT SIGNATURE CERT TION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, `ite ate, and in full compliance with legal requirements. APPLICA S1 ATURE DATE ��' y 470. -. APPLI NAME(print 471. APPLICANT TITLE 72. UPCF UST-13-1/2 Rev.(12/2007)