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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,II,H1,IV,and IX below) 430. ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ AATGE OF INFORMATION [16.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE S.UST REMOVAL DATE UST PERMANENTLY CLOSED. 410& DATE MUSTING UST DISCOVERED: r() Z O 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) t• PSn -��ngBuslnessAs)SanteasFacility amaorDBA3. 4a CZ1 14 d BUSINESS SITE ADDRESS CTT�� ton• II. TANK DESCRIPTION TANK ID# 432• TANK MANUFACTURER 433• -1:0K CONFIGURATION:THIS TANK IS 434. t '\ ,\ 1.A STAND-ALONE TANK Complete one page for each lJ N 2.ONE INA COMPARTMENTED UNIT compa,hncnt in ffi8 MiT D ST YSTEM INSTALLED 435- TANK CAPACITY IN GALLONS 436• NUA4ER F COMPARTMENTS IN THE UNIT 431 a�gx 110,15 Aq 13 III. TAN USE AND CONTENTS TANKUSE ❑ Ia.MOTORVEHICLEFUELING ❑ W MARINAFUELING ❑ 1c.AVIATIONFUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑f!IiAZARDOUS WAS TE(tadodes Used O f) ❑ 5.EMERGENCY GENERATOR FUEL[HSC¢252815(e)[ ❑ 6.OTHER GENERATOR FUEL 95.UNKNOWN ❑ 99.OTHER(Specify): 439& CONTENTS PETROLEUM; ❑ Ia.REGULAR UNLEADED ❑ to.MIDGRADE UNLEADED ❑ 1b.PRE,bIIUMUNLEADED 440• ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS M ❑ 8.PETROLEUM BLEND FUEL [19.OTHER PETROLEUM(S -i ): 440& N ,t-PETROLEUM:[17.USED OIL ❑ 10.ETHANOL ❑ 1I.OTHER NON-PETROLEUMS ify: 440b. IV. TANK CONS RUCTION TYPE OF TANK ❑ L SINGLE WALL ❑ 2.DOUBLE WALL 95.UNKNOWN 443. PRIMARY CONTAINMENT ❑ 1,STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444, _ ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER Specify): 444x. SECONDARY CONTAINMENT ❑ 1.STEEL [13.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445, ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OT14ER(Specify): 445& OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 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,SrNGLE WALL ❑ 2.DOUBLE WALL ❑ 99.OTHER 460. SYSTEM TYPE ❑ I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTIGN ❑ 4.SAPS SUCTION 1p CCR§2636(a 3 459. PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 461& SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464b- [1 90.NONE _ ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUNIP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE 1VALL ❑ 90.NONE 46td VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99,OTHER(Specify): 466441 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99,OTHER(Specify): 4464 641 4 VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NOME ❑ 99.OTHER(Specify): Zi. VR SECONDARY CONTAINMENT_ [1 L STEEL [14.FIBERGLASS ❑ 10,RIGID PLASTIC [190.NONE [199,OTHER(Specify): 464hhj VENT PIPING TRANSITION SUA4P TYPE _ ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.N0,IE 41. RISER PRIMARY CONTAINMENT [j1.STEEL [14.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464,. ' RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46641 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATEJBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45 a-c. VII, UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469& CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 6� VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. M. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is trite, accurate and in full compliance with legal requirements. APPLICANT SIGNATURE DATE z 470. a49! APPLICANT NAME(print) 431' APPLICA TITLE -R 472' UPCF UST-13 Rev.(12/2007)-1/2 51ww.unidocs.org