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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 430 ❑ L 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: 430a I DATE EXISTING UST DISCOVERED: 43ob I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) i BUSINESS N E(Same as FACILITY NAME or DBA-Doing Business As) -y� 3 n A ') A_. BUSINESS SITE ADDRESS iO3 I CITYIN 09 C II.TANK DESCRIPTION TANK ID It 432 TANK MANUFACTURER 431 TANKCONFIGURAT[ON' THISTANK IS 434 E]1.A STAND-ALONE TANK 4 3 TP C s w-ILI ❑2.ONE INA COMPARTMENTED UNIT. Com tete one livefor each wm annnit in We mdt. DATE UST SYSTEM INSTALLED 435 TANK C CITY IN GA'TiPNS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 A av0 C L.:GLt_1 III.TANK USE AND CONTENTS TANK USE I)� Ia.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ I..AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE nmludee Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL IHSC§25291!d,,)] ❑ 6.OTHER GENERATOR FUEL 0 95.UNKNOWN ❑ W.OTHER(Specify): 439. CONTENTS PETROLEUM: ❑ Is.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 440. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUMS ei : 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ LSINGLEWALL 2.D0UBLEWALL 095.UNKNOWN 443 PRIMARY CONTAINMENT ❑ I.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER444 ❑ 7.STEEL INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER S 444. SECONDARY CONTAINMENT ❑ 1.STEEL IN 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ %.NONE ❑ 95.UNKNOWN ❑99.OTHER (Specify): 445. OVERFILL PREVENTION I.AUDIBLE&.VISUAL ALARMS 0 2.BALL FLOAT 03.FILL TUBESHUT-OFFVALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE W 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR$2636(.X3)1 458 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS m 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464,, PIPINGf11JRBINE CONTAINMENT SUMP TYPE ❑ I.SINGLE WALL ❑ 2-DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC El90.NONE Cr99.OTHER(Specify) 464e 'N'el VENT SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS D 10.RIGID PLASTIC F1 90.NONE E3 99.OTHER(Specify) 464f 4114n VR PRIMARY CONTAINMENT 0 L STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC D 90.NONE 0 99.OTHER(Specify) 4648 464'1 VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS El 10.RIGID PLASTIC 0 90.NONE D 99.OTHER(Specify) 4Nh 6 61 VEIN PIPING TRANSITION SUMP TYPE L SINGLE WALL 2.DOUBLE WALL 90.NONE 464i. RISER PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE D 99.OTHER(Specify) 4641 4641 RISER SECONDARY CONTAINMENT 0 L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE D 99.OTHER(Specify) 4[Nk 464k1 FILL COMPONENTS INSTALLED L SPILL BUCKET 3.STRIKER PLATEIBOTTOM PROTECTOR 4.CONTAINMENT SUMP 4 NkI VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE Q 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ I.STEEL a 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bo VOL CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION aa- IX. APPLICANT SIGNATURE -d CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided keds true,accurate, and in full compliance with legal requirements. APPLICANT SIGNATURE E �/[9) o 470. DAT APPLICANT NAME(print) °01- APPLICANT TITLE °n +4, UPCF UST-B-112 Rev.(122007)