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MIA UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One foam per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,Ell,IV,and IX below) 430 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL 430bDATE UST PERMANENTLY CLOSED: 43oa DATE EXISTING UST DISCOVERED: L FACILITY INFORMATION 1 FACILITY ID#(Agency Use Only) _ - BUSIN SS N E(Same as FACIL Y N or DBA-Doing Business As) 3 A-.; m9 J toa BUSINESS SITE ADD SS 103 CITY /� M ? II.TANK DESCRIPTIO TANK ID#-22 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 ❑1.A STAND-ALONE TANK ❑2.ONE IN A COMPARTMENTED UNIT. Cornplate oae page for eachcompartaieritiii the unit. DATE UST SYSTEM INS ED 435 TANK CAPACITY IN GALLON 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 /® ;0 IIL TANK USE AND CONTENTS TANK USE Is,MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑4.HAZARDOUS WASTE OwMes Used Oil) ❑ S.EMERGENCY GENERATOR FUEL[FISC§25281.5(c)l Q 6.OTHER GENERATOR FUEL ❑95.UNKNOWN ❑99.OTHER(Specify): 439a CONTENTS PETROLEUM a[ la.REGULAR UNLEADED ❑ 1c.MIDGRADE UNLEADED ❑ Ib.PREMUM UNLEADED 440 ❑ 3.DIESEL ❑5.JET FUEL ❑6.AVIATION GAS 13 8.PETROLEUM BLEND FUEL 139.OTHER PETROLEUM S 440a NON-PETROLEUM❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHERNON PETROLEUM(specify): 44ob IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL 2.DOUBLE WALL ❑95.UNKNOWN 443 PRIMARY CONTAINMENT i.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEM+INTERNAL LINING 0 95.UNKNOWN ❑ 99.OTHER (S ): a44a SECONDARY CONTAINMENT j2r 1.STEEL U8.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 13 90.NONE fa 95.UNKNOWN ❑99.OTHER i >: 445a OVERFILL MVENTION 1.AUDIBLE&VISUAL ALARMS M 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQ NTS FOR EXBVTIONFROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPPING CONSTRUCTION ❑1.SINGLE-WALLED 122.DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE ff 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR§2636(a)(3)) 458 PRIMARY CONTAINMENT ❑ 1.STEEL A 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL jar 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINIviENT SUMP TYPE ja 1.SINGLE WALL ❑ 2.DOUBLE WALL 0 90.NONE 4tad VL VENT,VAPOR RECOVERY(YR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT U 1.STEEL fir4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT T ❑ 1.STEEL ®4.FIBII2GLASS ❑ 10.RIGID PLASTIC ❑90.NONE ❑ 99.OTHER(Specify) 464f ®. 464fl VR PRIMARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 VR SECONDARY CONTAINMENT 0 1.STEEL JU 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑90.NONE ❑ 99.OTHER(Specify) 464h 464M VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL ❑90.NONE 4641. RISER PRIMARY CONTAINMENT L STEEL U 4.FIBERGLASS 10.RIGID PLASTIC 13 90.NONE ❑ 99.OTHER(Specify) 464i I RISER SECONDARY CONTAINMENT Q 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑90.NONE ❑ 99.OTHER(Specify) 464k 14 464k1 FILL COMPONENTS INSTALLED jaI.SPILLBUCKET J03.STRUCERPLATFJBOTTOMPRoTEcroR j14CONTAINNIENTSOW 45lac VIL UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE JM 1.SINGLE WALL ❑ 2.DOUBLE WALL Q 3.NO DISPENSERS ❑ 90.NONE 46% CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b-c VIIL CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION AIlq 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 ruirements azo. APPLICANT ATURE DATE APPLICANT NAME(print) r an. APPLICANT TITLE , 472. e t fir' UPCF UST-B-112 Rev.(12!2007)