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UNIFIED PROGRAM CONSOLIDATED FORM J UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (One form per UST) OF ACTION (Check one item only. For an UST pert closlae or removal, complete only this section and Sections I, II, III, IV, and IX below) 430 I. NEW PERMIT ❑ 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 6. TEMPORARY UST CLOSURE 7. UST PERMANENT CLOSURE ON SITE 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: DATE EXISTING UST DISCOVERED: 4306 I. FACII.TTY INFORMATION FACILITY m # (Agency Use Onty) I BU INESS NAME (Same as FACILITY NAkIE or DBA -Doing Bs'nea As) 3 BUSINESS SITE ADDRESS to, CITY 104 TR TA)VV-nF-4 1DYPT1rnA1 TANK ID # T �5l 75a a32 TANK MANUFACTURER 433 CoNFiGURATIow THIS TANK is 434 TANK [11. A STAND-ALONE TANK C�\o32`t$ \ L �ONEINACOIMPARTMENtmuw. IyJr)plJ�`fi�-?:►Cc� in the DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMP IN THE UNIT 437 Ic IITAM USE A" CONTENTS TANK USE ❑ la. MOTOR VEHICLE FUELING ❑ lb. MARINA FUELING ❑ la AVIATION FUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE awWda Used oil) ❑ 5. EMERGENCY GENERATOR FUEL W I2528I.5(cp ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ".OTHER (Specify): 439. TE CONTENTS PETROLEUM [3la REGULAR UNLEADED ❑ Ic MIDGRADE UNLEADED ❑ Ib. PREMIUM UNLEADED 440 ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 84MOLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM S 440a NON -PETROLEUM: Q0,JdS%D OI ❑ 10. ETHANOL [.OTHER NON -PETROLEUMS ): 4406 :.:TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL fW 2. DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT 03. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 J; 7. STEEL. + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (S 444a SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 3. FIBERGLASS a❑ 6. EXTERIOR MEMBRANE ❑ '7, J CKETED 445 ❑ 90. NONE ❑ 95. UNKNOWN 099.OTHER (specify): _ Li 445a OVERFILL PREVENTION P l UDBLE & VISUAL ALARMS U 2. BALL FLOAT El 3. FILL TUBE SHUT VALVE 451 4. TANK MEETS REQUIRJDbMNTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT./ WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION DI -SINGLE -WALLED 2. DOUBLE•WALLED ❑ 99.OTHER 460 SYSTEM TYPE PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION CCR f2636(.X3)1 458 PRIMARY CONTAINMENT STEEL ❑ 4. FIBERGLASS ❑ & FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTIIBR(Specify): 461 SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE l0. RIGIDPLAS')C 460 ❑ 90. NONE ❑ 95. UNKNOWN g 99. OTHER (Specify): - ' ;{. 469e PIPING/I'URBINE CONTAINMENT SUMP TYPE ❑ I. SINGLE WALL U 2. DOUBLE WALL 90. NONE 464d VL VENT, VAPOR` COVERY ") AND RISER/ FILLPIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT Ukrl. STEEL 0 4. FIBERGLASS 0 10. RIGID PLASTIC 0 90. NONE 0 99. OTHER (Specify) 464e VENT SECONDARY CONTAINMENT 0 1. STEEL 0 4. FIBERGLASS 0 10. R1GID PLASTIC 13 90. NONE E3 99. OTHER (Specify) 464el 464E VR PRIMARY CONTAINMENT E3 I. STEEL 0 4. FIBERGLASS ❑ 10. RIGID PLASTIC 0 90. NONE 0 99.OTHER (Specify) 464fl 4648 VR SECONDARY CONTAINMENT 1. STEEL 0 4. FIBERGLASS 0 10. RIGID PLASTIC 0 90. NONE C3 99. OTHER (Specify) 464aI 64h VENT PIPING TRANSITION SUMP TYPE 0 1. SINGLE WALL 13 2 DOUBLE WAIL 90. NONE 464614 4641 RISER PRIMARY CONTAINMENT Lj 1. STEEL 0 4. FIBERGLASS ❑ 10. RIGID PLASTIC 0 90. NONE C3 99. OTHER (Specify) 4641 RISER SECONDARY CONTAINMENT 1. STEEL 0 4. FIBERGLASS 10. RIGID PLASTIC 90. NONE 99. OTHER (Specify) 4617 461t 464k1 FILL COMPONENTS INSTALLED El I. SPIL BUCKET 3. STRw.ER PLATvBOTrom PROTECTOR 4. CONTAINMENT SUMP 451" VII. UNDER DISPENSER CONTAINMENT.(UDC). CONSTRUCTION TYPE ❑ 1. SINGLE WAIL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS . NONE 469a CONSTRUCTION MATERIAL 0 1. STEEL 0 4. FIBERGLASS 0 10. RIGID PLASTIC 13 99.OIiIBR (Specify) 469b e VUL CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT 6. ISOLATION 44& UL APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous sabrt>vee stored and that the information provided herein is true, accurate, and L fall compliance with legal requiremesm APPLICANT SIGNATURE DATE 1 O DC7(LA 470. APPLICANT NAME(print) 411. APPLICANT TITLE 47Y \ UPCF UST -B - 1/2 Rev. (12!2007) 4 ASr- n