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• FlECEIVED , <br /> UNIFIED PROGRAM CONSOLIDATED FORM �A 11'��� <br /> UNDERGROUND STORAGE TANK 'V V AIAAC�('� <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION x 'I SIE Y <br /> E OF ACTION (Check one item only. For an UST pesmanrnt closure or removal,complete only this section and Sections I,IL Ill,IV,and Lk 430 <br /> •NEW PERMIT n 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> 6.TEMPORARY UST CLOSURE 1 7.UST PERMANENT CLOSURE ON SITE S.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: i(J 43NDATE EXISTING UST DISCOVERED: <br /> ... y .n .. f5 <br /> FACILITY ID#(dgenry Use Only) <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 <br /> K o ir.W!®a s/>� 1514 -VEO Fid <br /> s%a7o�J <br /> BUSINESS SHE ADDRESSSo✓l� {�?O la3 ���� ,a <br /> TANK ID# 432 TANK MANUFACTURER- S433 aTANK <br /> CONFIGURATION: THIS TANK Is 434 <br /> / J 1 s!I�1 ASTAND-ALONE TANK <br /> -1 ND Z j d �O 411)K [12.ONE IN A COMPARTMPNTED(IMT. <br /> ma's' <br /> ao eeme farack can entmae aaL <br /> DATE UST SYSTEM INSTALLED 435 TANK CAPAC Y IN GALLONS 436 NUMBER s' ARTMENTS IN THE UNIT 437 <br /> �✓ l/�tJ�1a£ <br /> TANK USE =.::. <br /> [I MOTOR VEHIIa. OTCLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AV1ATIONFUELING 439 <br /> ❑3.CHEMICAL PRODUCT STORAGE ❑�/4�.HAZARDOUS WASTE(Indudallsrd 00) ❑ 5.EMERGENCY GENERATOR FUEL IBSC 425281.5(.)1 <br /> (16.OTHER GENERATOR FUEL. :S.UNKNOWN ❑ 99.OTHER (Specify): 439. <br /> CONTENTS PETROLEUM: ❑ Is.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ S.PETROLEUM BLEND FUEL .OTHER PETROLEUM S m O7p.Z /L Alr 440a <br /> NON-PETROLEUM:E3 7.USED OIL ❑ {O.ETHANOL <br /> II.OTHER NON-PETROLEUM S eci : 44M <br /> TYPE OF TANK 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN qq3 <br /> PRIMARY CONTAINMENT ®.I.STEEL ❑ 3.FIBERGLASS ❑ 6.IN7ERNAL BLADDER 4aa <br /> ❑ 7.STEEL+INTERNAL LINBJG ❑ 95.UNKNOWN ❑ 99.OTHER S cif 444. <br /> SECONDARY CONTAINMENT ❑ I.STEN. ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.7pCKETED 445 <br /> 90.NONE ❑ 95.UNKNOWN ❑99.OTHERS if 445. <br /> OVERFILL PREVENTION I.AUDIBLE aVISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE N/9 452. <br /> ❑ 4.TANKMEET$REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> �{�• .,_. ,.... .r� fir. _. .. <br /> ,... '..- ,-. -: . s..+�+T?"'+ii:�4f FJSslkFA'^r,5]11 ��'.����,t• Qaa<#,'. <br /> PIPING CONSTRUCTION ❑ISINCLE-WALLED ❑2.DOUBL&WALLED ❑990THER �/O.✓t 460 <br /> SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY .CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 113 CCR 42636(.x3) 458 <br /> PRIMARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS ❑ a.FLEXIBLE ❑ Io.RIGID PLASTIC 464 <br /> 90.NONE ❑ 95.UNKNOWN- ❑ 99,OTHER(Specify): 464a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL, ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b <br /> 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c <br /> PIPING/rURBINE CONTAINMENT S 411 TYPE Cl 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 4646 <br /> vEly7iQSl#iavERX;`€t M1�IIY?tiS$I7. k pfYEI�I�G3G� lYrTtF? f: <br /> VENT PRIMARY CONTAINMENTI.STEEL /.FIBERGLASS 10.RIGID PLASTIC 90.NONE U MOTHER(Specify) 4644 <br /> VENT SECONDARY CONTAINMENT 01.STEEL 0 4-FI...VLASb 464.1 <br /> ❑ 10.RIGID PLASTIC 0.NONE 99.OTHER(Specify) 464f <br /> 4MO. <br /> VR PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC O.NONE 99.OTHER(Specify) 4648 <br /> VR SECONDARY CONTAINMENT 464 1 <br /> ❑ 1.STEEL 1.PIBERGLASS 10.RIGID PLASTIC 0.NONE 99.OTHER(Specify) 464h <br /> 4Mhl <br /> VENT PIPING TRANSTffON SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL '.NONE 4641. <br /> RISER PRIMARY CONI MNMF I U 1.STEEL U C FIBERGLASS Ll 10.RIGID PLASTIC 0.NONE 99.OTHER(Specify) 4Mj <br /> 464'1 <br /> RISER SECONDARY CONTAINMENT - LSTEEL LFIBERGLASS 10.RIGID PLASTIC 0.NONE 99.OTHER(Specify) 4Mk <br /> FILL COMPONENTS INSTALLED LSPILL BUCKET 3.STR�I yK��RgPLATBOTTOM PROTECfOft 4.CONTAINMEN75UMP 4&1k)n7ch9i 451a-c <br /> .. '. . . F/ <br /> �!IIE ;A P_E13S 11 , q� _aD <br /> CONSTRUCTION TYPE L SINGLE WALL ❑ 2.DOUBLE WALL ❑ J.NO DISPENSERS 90.NONE 46% <br /> CONSTRUCTION MATERIAL ❑ I.STEEL 4.FIBERGLASS ❑ I0.RIGID PLASTIC ❑ 99 Of (S e, ) 4696< <br /> STEEL COMPONENT C . <br /> �r�giul4sraN✓��t���.Tla�v; <br /> PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION tVAK 448 <br /> ?% APLiLIC'ANI SIFsNATURE <br /> CERTIFICATION: 1 certify that this UST system Is compatible with the hazardous substance stored and that the Information provided herein is true,accurate, <br /> and In full com liance with legal requirements <br /> APPLICANT SIGNATURE DATE `�S 470 <br /> APPLICANT NAME(print)' 4J1. APPLICANT TPLLE 472. <br /> UPCF UST-B-1/2 <br /> Rev.(122007) <br /> /L <br />