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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION -TANK INFORMATION (one Eorin per UST) EYPE OF ACTION (Check one item only. For an UST permanent closure or removal. complete only this section and Sections I, H, 111. IV, and IX below) 1•tn ❑ 1. NEW PERMIT ,eJ 3. RENEWAL PERMIT ❑ S. CHANGE OF INFORMATION (i. TEMPORARY USC CLOSURE ❑ 7. US'r PERMANENT CLOSURE ON SITE Ej 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: '"nDATE EXISTING UST DISCOVERED: 4 nn 1. FACILITY INFORMATION FACILITY ID # (Ageucv UseO+tl),.) BUSINESS NAiYIE (Same as FACILI'T'Y NAME or DBA -Doing Business As) �'o s Its BUSI NESS AITE ADDR5S toy CITY Sf %L� "'' r ZfLL L l C i7/ G rf1 11. TANK DESCRI PTI ON TANK IDn 43: TANK MANUFACTURER 433 1 TANKCONROURATION: THIS TANK IS 434 Z1. A SI:AND-ALONE TANK 0 3c1J�4�3 /(�rLJV(GSIL(V� ❑2.ONE INACOMPARTME•NTEDUNIT. (J J ( l Cron Ieie one paim ror each cam :ntmeni in dte 11.111. DATE"S,l'Sl'STEM INSTALLED 435 TANK CAPACITYIN GALLONS 4x NUMBER OF OMPARTMENTS IN THE UNIT ;" IM 000 III. TANK USE AND CONTENTS 'LANK USE Ia. MOTOR VEHICLE. FUELING ❑ Ib. MARINA FUELING ❑ Ic. AVIATION FUELING .130 F(�] ❑ 3. CHEMICAL PRODUCT STORAGE ❑ •1. HAZARDOUS WASTE (hicludw Used Oil) ❑ 5. EMERGENCY GENERATOR FUEI. It•ISC 425291 *)l ❑ 6.OTHER GENERATOR FULL ❑ 95. UNKNOWN ❑ 99, OTHER (Specify): 4.311° CONTENTS PETROLEUM: ❑ In. REGULAR UNLEADED ❑ Ic. MIDGRADE UNLEADED ❑ Ib. PRENHUhI UNLEADED 440 ,L3-3. DIESEL ❑ 5. AL ' FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUNI BLEND FUEL ❑ 9, OTI PETROLEUM (S ecifi•): '1'llta NON -PETROLEUM: ❑ 7. USED 011. ❑ 10. ETIIANOL ❑ 11. OTHER NON -PETROLEUM (S lecirv): 4401. IV. TANK CONSTRUCTION TYPEOFTANK ❑ I. SINGLE WALL -. DOUBLE WALL. ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT ❑ I. STEEL �� FIBERGLASS [16. INTERNAL. BLADDER .14'1 ❑ 7.S'1'EEI_+INTEItNAL.LINING ❑ 95. UNKNOWN ❑ 99. OTHER (S Lcil'y): I'31n SECONDAkY CONTAINMENT ❑ 1. S'PEL'L .01. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7AACKE7'ED 415 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99 OTHER (S 3ecilj' ): 445a OVERFILL PREVENTION [1I. AUDIBLE S VISUAL AL ARNIS ❑ 2. BALL FLOAT 3. FILL TUBE SMUT -OTT VALVE. •152 0 t. TANK MEETS REQUIREMENTS FOR LXENIPTION FROs10VERP11_I- PRL'VL-'N'rION L•QUIPMT.•.NT V. PRODUCT / WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ I. SINGLE -WALLED _. DOUBLE -WALLED ❑ 99. OTIIER 460 SYSTEM TYPE ❑ 1. PRESSURE ❑ - GRAVITY CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION 123 CCI( §36.ti4aN 311 458 PRINIARYCONTAINNIENI' ❑ 1. STEEL •1 FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 4.8 ❑ 90. NONE ❑ 95. UNKNUIL'N ❑ 99.OTIIF:R(Spccil'y): 41i4j SECONDARY CONTAINMENT ❑ I. STEEL � 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ I0. RIGID PLASTIC 464h ❑ 90, NONE ❑ 95. UNKNOWN ❑ 99. OTI IFR (Specify): 46.1c PIPINGl1'URBINE CONTAINMENT SUNIP TYPE El SINGLE: WALT_ 2. DOUBLE WALT. ❑ 90. NONE 46.Id VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT Lj 1. S9EL•LJ FIBERGLASS 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Speciry) 464e4&W ,,2-4. ,j'4I. FIBr:RGL.ASS ❑ 10_ RIGID PLASTIC 90. NONE. ❑ 9% 0 i*TIER (Specitp) 464f VL"N'I' SECONDARY CONTAINMENT I. STEEL46411 VR PRIMARY CONTAINMENT ❑ I. STEEL 4. FIBERGLASS ❑ 10. RIGID PLASTIC Ll 90. NONE Cj 99. 0-111 L'It (Specify) 4646 464.1 VR SECONDARY CONTAINMENT ❑ 1. STEEL •❑ 4. FIBL'RGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. D'rHER (Specify) •{64h 4u•Ihl VENT PIPING TRANSITION SUMP TYPE ❑ 1. SINGLE WALL 2. DOUBLE WALL ❑ 90. NONE •164. RESER PRIMARY CONTAINMENT ❑ I. S'I'GHL 4. FIBERGLASS ❑ 10. RIGID PLAS'T'IC ❑ 90. NONE Lj 99. OTI IER (Specify) 4641 .164 I RISER SECONDARY CONTAINMENT ❑ I.STEEL Q-4.17IBERGLASS 10.R1GIDPLrASPIC ❑ 90. NONE ❑ 99.OTI IER(Specify) 4(4k 464ki FILL COMPONENT'S INSTALLED SPILL BUCKET 3. STRIKER PI_A'1EtBO'I-TOM PROTECTOR ❑ 4. CONTAINMENT SUMP 45la-c VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ❑ I. SINGLE WALL❑ .. DOCIBI_E WALL ❑ 3. NO DIS!'ENSE-RS El 90. NONE 4f'" t GLASS 10. IGIDPLASTIC ❑ 99. OTHER (Specify) *c CONSTRUCTION MATERIAL ❑ L STEEL X1-4. FIBERR VIII. CORROSION PROTECTION STEEL CONIPONL•NT PROTECTION ❑ 2. SACRIFICIAL. ANODE(S) ❑ •1. IMPRESSED CURRENT ❑ 6. ISOLATION 1'i� 1X. APPLICANT SIGNATURE CER'CIFICATION: I certify that this LIST system is compatible with the hazardous snbstnnce stored and that the infurmatiun provided Itercin is Irne, accurate. and in full Compliance with legal ret uircntcals. Al''Lh 'A. 'IGNA'rURE G t47oA DATE:_ 1 _v d-07 LICANT ME nnl) d7i. APPLIC�} NT'll"I'LE��J Ir_ c L d 1 �fllzll.Ct LII'CF UST -11-112. Re V. (12/2007) 1.,.