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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per USTI. M�-- TYPE OF ACTION (Check one item oor a USTclosstre or removal,complete only this section and Sections 1,11,111,]1,*,and IX below) -430.- 0 1.NEW PERMIT X 3.RENEWAL PERMIT D 5.CHANGE OF INFORMATION 0 6.TEMPORARY UST CLOSURE _ 0 7,UST PERMANENT CLOSURE ON SITE 11 8.UST REMOVAL DATE LIST PERMANENTLY CL• M t -430b. L FACI]LITY INFORMATION 111,12[81111 If VA 577F IT M, IRTM,M IN I Off TANK ID# 432. TANK MANUFACTURER 431 4 OWENS CORNINGA,t9 94M DATE LIST SYSTEM INSTALLED 435- TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. . r0 III. TANK USE AND CONTENTS TANK USE 0 Ia.MOTOR VEHICLE FUELING 0 ib i ELING 0 3.CHB41CAL PRODUCT STORAGE 0 4.HAZARDOUS WASTE [I (includes Used 00) El 5.EMERGENCY GENERATOR FUELIMC§25281.5(c)] 6,07HER GENERATOR FUEL D 95.UNKNOWN [3 ".OTHER(Specify): 439a. (�-ONTENTS PETROLEUM: 0 Ia.REGULAR UNLEADED 0 Ic.MIDGRADE UNLEADED 11 lb-PREMIUM UNLEADED 440, 0 3.DIESEL 0 5.JET FUEL E3 6.AVIATION GAS 0 8,PETROLEUM BLEND FUEL Q 9.OTHER PETROLEUM(Specif�): 44M. NON-POi6LECQ:[1 7.USED OIL U 10.ETHANOL E3 11.OTHER NON-PETROLEUM 440b. IV. TANK CONSTRUCTION TYPE OF TANK 1.SINGLE WALL 19 2,DOUBLE WALL 0 95.UNKNOWN 443. PRIMARY CONTAINMENT C) 1.STEEL 0 3.FIBERGLASS [3 6.INTERNAL BLADDER 444. 7.STEEL+INTERNAL LINING E3 95.UNKNOWN r-1 99.OTHER(Specify): 444a. SECONDARY CONTAINMENT C3 1.STEEL 0 3.FIBERGLASS [:] 6.EXTERIOR MEMBRANE LJNER [71 7.JACKETED 445. 13 90.NONE 0 95.UNKNOWN [3 99.OTHER(Specify): 445a. OVERFILL PREVENTION 19 1.AUDIBLE&VISUAL ALARMS [1N 2.BALL FLOAT 452.3.FILL TUBE SHUT-OFF VALVE 0 4,TANK MEETS REQUIREMENTS FOR DCEMPTION FROM OVERFILL PREVENTIgh!WUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 0 1,SINGLE WALL H 2. AWAUL 13 99.OTHER SY§-T-Ekt-YPE 0 1.PRESSURE [3 2.GRAVITY D 3.CONVENTIONAL SUCTION [1 . SAFE SUCTION[23 CCR§2636(aX3)] 45V PRIMARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS 0 R.FLEXIBLE 0 10.RIGID PLASTIC -464 E■l 90,-NONE ■ 95.UNKNOWN 0 9�:OTNE"( p!Fj SECONDARY CONTAINMENT 1.STEEL IN 4.FIBERGLASS [3 9.FLEXIBLE E3 10.RIGID PLASTIC 464b. 90.NONE [3 gs.UNKNOWN [3 99.OTHER(Spnify): 464r L [1 2.DOUBLE WALL El 90.NONE 464d. VI. VENT,,VAPOR RECOVERY(VR)AND RISER/FML PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT [1 1.STEEL C9 4,FIBERGLASS [] 10.RIG-ID PLASTIC 0 90.NONE 0 99.OTHER(Specify): 464al. VENT SECONDARY CONTAINMENT [3 1.STEEL 0 4.FIBERGLASS E3 10,RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify): -4"E VR PRIMARY CONTAINMENT 1.STEEL N 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE [3 99.OTHER(Simcify): VR SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE [1 99.OTHER(specify): 64bl, VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 13 2.DOUBLE WALL El 90.NONE 464t- RISER PRIMARY CONTAINMENT [1 1.STEEL 4.F113ERGLASS 0 10.RIGID PLAS71C [3 90.NONE 0 99.OTHER(Specify): 4641.. 464il. RISER SECONDARY CONTAINMENT C) 1.STEEL M 4.FIBERGLASS [3 10.RIGID PLASTIC 0 90.NONE [3 99OTHER(Specify): 4641:1. FILL COMPONENTS INSTALLED 0 1.SPILL BUCKET [j 3.STRIKER PLATEIB0770M PROTECTOR 4.CONTAINMENT SUMP 45la-c. VII. UNDER DISPENSER CONTAINNIENT(UDC) VIII. CORROSION PROTECTION II YA STEEL COMPONENT PROTECTION [1-2.SACRIFICI L ANODE(S) 4.IMPRESSED CURRENT 0 6.ISOLATION 44. APPLICANT SIGNATURE APPLICANT NAME(ptint) JEFF LARSEN 471.