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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One fomi per UST) TYPE OF ACTION (Check one ite7n only. For a UST closure or rentorat complete only this section and Sections 111,111,IV,,and IX beton) 430. ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT Q�e&ANGE OF INFORMATION 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: ✓ 4302. DATE EXISTINIO UST DISCOVERED: 1 t7 430b. I FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESTf14i6_,) ME(Sante as Fac7ity raure or DB -DoingBusiness 37 lu__ D• QSa ADDRESS � ,� 103. cTTy � r � � los. JTZj II.`:TANK DESCRIPTION TANK ID 4 432• TANK MANUFACTURER 433• TANK CONFIGURATION:THIS TANK IS 434. 304! }� ' \ Er ASTAND-ALONE TANK Complete V omp page for each (/ 0UJ N ❑ 2.ONE IN A COMPARni IMTED UNIT wmPartmeat in the unit DATE U T SYSTEM INSTALLED 435• TANK CAPACITY IN GALLONS 436. NtItIE OF COMP Ti1lENTS IN THE UNIT 43�- I III.`TANK VSE AND CONTENTS TANK USE ❑ la MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Ic.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)l ❑ 6.OTHER GENERATOR FUEL V95.UNKNOWN ❑ 99.OTHER S i5,): 4398 CONTENTS PETROLEUM: ❑ Is.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 449, r u' ` ❑ 3.DIESEL El 5.JET FUEL ❑ 6.AVIATION GAS V N ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 4402. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHERNON-PE71ROLEUM(Specify); 440b• IV. TANK CONTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 9 95.UNKNOWN 443. PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 3.FIBERGLASS ❑6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444x. SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445• ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 4452. 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.SINGLE WALL_❑ 2.DOUBLE WALL ❑ 99.OTHER _ 460. SYSTEM TYPE ❑ 1.PRESSURE El 2.GRAVITY �❑ 3.CONVENTIONAL SUCTION [14.SAFE SUCTION 23 CCR§263 a 3 458. PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464• ❑90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4642. SECONDARY CONTAINMENT ❑ 1.STEEL ❑4.FIBERGLASS ❑ 9.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464e. PIPINGIIURBINE CONTAINMENT SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI 'VENT,VAPOR RECOVERY(VR)AND RISER%FILL PIEE PIPING CONSTRUCTION ` VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4644ej. _VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Speci5l): 4464f VR PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4648. 464A. VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NTONE ❑ 99.OTHER(Specify): 4469L VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE.WALL ❑ 2.DOUBLE WALL ❑ 90.NONE UX RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4 . RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464k1. FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATEIBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 4 to a VII. UNDER DISPENSER CONTAINMENT.(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 4692. CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 69c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES ❑ 4.LIIPRESSED CURRENT ❑ 6.ISOLATION 448• IX. 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 corn liance 33ith le al requirements. APPLICANT SIGNATURE DATE 470. APPLICANT NAME(print) 471. APPLICANT Tl E 472. S UPCF UST-B Rev.(12/2007)-IIZ 33%v%v.unidocs.org