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i�VIFIED PROGRAM CONSOLIDATED UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per US, 1� TYPE OF ACTION (Check one item only. For an UST permanent closure or ren3oval,complete only this section and Sections 1,B.III,IV,and IX below) 430 Cl I.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE ❑ Z UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: "' I DATE EXISTING UST DISCOVERED: 43% 1. FACILITY INFORMATION FACILITY 1D#(Agency Use Only) _ _ ^l t BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) `� 3 Circle K#2701205 BUSINESS SITE ADDRESS 5N CITY 5a 16470 CambridgeLa limp ❑.TANK DESCRIPTION TANK ID# 2 432 TANK MANUFACTURER 435 TANK CONFIGURATION: THISTANKIS 434 rt Owens Coming M LA STAND-ALONE TANK D /.F.' ❑2.ONE IN A COMPARTMENTED UNIT, CJ F lan oma rore nna tin tha wit DATE UST SYSTEM INSTALLED 455 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 11849 1 t ❑1.TANK USE AND CONTENTS TANK USE 0 la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc,AVIATION FUELING439 [I ].CHEMICAL PRODUCT STORAGE E] 4.HAZARDOUS WASTE(Imludm Used oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC 4252815(.)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ 1 c MIDGRADE UNLEADED ® Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.SET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM,BLEND FUEL ❑ 9,OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 1 I OTHER NON-PETROLEUM(Specify) 4406 IV. TANK CONSTRUCTION TYPEOFTANK ❑ L SINGLE WALL ® 2.DOUBLE.WALL 0 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S ify: NSe OVERFILL PREVENTION ❑ 1.AUDIBLE&.VISUAL ALARMS 2 BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 451 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED ®2.DOUBL&WALLED [199.OTHER 460 SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY 0 3.CONVENTIONAL SUCTION 0 4.SAFE SUCTION I23 CM 42636(a)(3R 458 PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS C3 8.FLEXIBLE ❑ IC.RIGIDPLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHERS ify): 464. SECONDARY CONUAINMENIT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(S .0y): 4Mc PIPINGIRJRBTNE CONTAINMENT SUMP TYPE ® I,SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4694 VL VENT,VAPORRECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT EI1.STEEL29 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 46.9e 464e1 VENT SECONDARY CONTAINMENT El L STEEL In 4.FIBERGLASS ❑ 10.RIGID PLASTIC N 90.NONE ❑ 99.OTHER(Specify) 4t f 4Mr VR PALMARY CONTAINMENT 8 ].STEW. ❑ 4.}TBEAGLASS C 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 4448 464 1 VR SECONDARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify) 46th a4"n VENT PIPING TRANSITION SUNUP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL 46q 90.NONT: . RISER PRIMARY CONTAINMENT ® L STEEL ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE U 99.OTHER(Specify) 4ey 469'1 RISER SECONDARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE 0 99,OTHER(Specify) 464n 4l FILL COMPONENTS INSTALLED I.SPILL BUCKET 0 3.STRIKER PLATF..BOTTOM PROTECTOR 0 4 CONTAINMENT SUMP 451st VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE.WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 460a CONSTRUCTION MATERIAL ❑ 1.STEEL % 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(.Specify) a691.. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.TSOI.ATION 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, rt and in full compliance with[gal requirements. APP IC AT >:' /c.- DATE �1)tal�\ 470. 6• LTCANT NAME 411 APPLICANTTITLE Environmental Compl, Mgr. 472. UPCF UST-B-Ia Rev.(1212007)