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01 AV aY..iJ A 1, Il UNIFIED PROGRAM CONSOLIDATED FORM J UNDERGROUND STORAGE TANKN OPERATING PERMIT APPLICATION-TANK INFORMATION V�'�O �J GENT_. TYYE OF ACTION (Check one item only. For sR UST permanent closure orremoval,complete only.this section and Sections L If,IH,IV,and IX d 430 Orl.NEW PERMIT L]3.RENEWAL PERMIT 0 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE_____Ll 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED "J DATE EXISTING UST DISCOVERED: II3I"*S Www - FACILITY ID#(Agency Ure Only) rUSESS NAME{Same as FACILITY NAME or DBA-Doing Business As) • TY) 3 K o rctir®,� sf>� c .rlE� Firms s%q7�1 SS SITE ADDRESS im CITY/�v la TLyICpS ' # / 43z TANK MANU`FACCURER 4" TANK CONFIGURATION: THIS TANK IS43a 11""1D L(I/✓I �b ��` 0"t -ALONE TANK ❑2.ONE IN A COMPARTMENTED UNIT. DATE UST SYSTEM INSTAL ED 435 One acme roreach.. ie the not TANK CAPAC Y INGALLONS 436 NUMBER OF�I ARTMENTS IN THE UNIT 437 ... .. TANK USE 0 Is.MOTOR VEHICLE FUELING 0 Ib.MARINA FUELING 0 Ic.AVIATION FUELING 439 0 3.CHEMICAL PRODUCT STORAGE 0 4.HAZARDOUS WASTE Mdu U4 qT) 0 5.EMERGENCY GENERATOR FUEL IHSC j=31.5(c)) 0 6.OTHER GENERATOR FUEL 5.UNKNOWN 0 99.OTHER Specify): 439. CONTENTS PETROLEUM: 0 Is.REGULAR UNLEADED 0 Ic.MIDGRADE UNLEADED 0 Ib,PREMIUM UNLEADED 440 0 3.DIESEL 0 5.JET FUEL 0 6.AVIATION GAS 0 8.PETROLEUM BLEND FUEL .OTHER PETROLEUM S eci 0704 /G �Ff✓ 440a NON-PETROLEUM:C] J.USED OIL ❑ l0.ETHANOL 11 OTHER NON PETROLEUM S «, 4406 TYPE OF TANK 1 SNGLE WALL 0 L.DOUBLE WALL LI 95 UNKNOWN 443 PRIMARY CONTAINMENT ®.1.STEEL 0 3.FIBERGLASS 0 6.INTERNAL BLADDER 063 ❑ 7.STEEL +INTEIINAL LDiING 0 95.UNKNOWN ❑ 99. OTHER 444a SECONDARY CONTAINMENT 0 L STEEL 1-13.FIBERGLASS 0 6.EXTERIOR MEMBRANEKETED 445 90.NONE 0 95.UNKNOWN 099.OTHER S NS. OVERFILL PREVENTION 1 AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FVALVE N/9 452 0 4 TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PRET .q.. z., ., .. _. PIPING CONSTRUCTION1_111 'Y .SINGLE-WALLED 02.DOUBLE,W w U 99 OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY .CONVENTIONAL SUCRON ❑ 4.SAFE SUCTION z)CCR 1636(aX3)] 458 PRIMARY CONTAINMENT I.STEEL 0 C FBSERGLASS 0 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 90.NONE 0 95.UNKNOWN 0 99.OTHER(Sp«ify): 464a SECOND A0.Y CONTAIN ENT El 1.STEEL, ❑ /.FIBERGLASS ❑ e.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 90.NONE 0 95.UNKNOWN 0 99.OTHER(R eci(y): 466e PIPMG?URBNE CONTAINMENT SU TYPE 0 1 SNGLE WALL ❑ z DOUBLE WALL 90 NONE 464d iVENTy:VALf SI}' VEnIr.. BJ Ft �acaavReTrt VENT PRIMARY CONTAINMENT 1.STEEL4.FIBERGLASS 10 RIGID PLASTIC 90,NONE ff 99.OTHER(Specify) 464e VENT SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 99.OTHER(Specify) I .NONE 4Mc1 VR PRIMARY CONTAINMENT U 1.STEEL U 4.FIBERGLASS 10.RIGID PLASTIC 0.NONE U 99.OTHER(Specify) 464g VR SECONDARY CONTAIN.. U 1.STEEL U 4.FIBERGLASS 13 10.RIGID PLASTIC .NONE 99.OTHER S t 464 ( 13ee fy) 4h VENT PIPING TRANSITION SUMP TYPE I.SNGLE WALL 444h1 2.DOUBLE WALL '.NONE 666' RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC .NONE 99..OTHER(Specify) 464j RISERSECONDARY CONTAINMENT LSTEEC 4.FD5ERGCASS 464' 10.AIGID PLASTIC O.NONE 99.OTHEE(Specify) 464k FILL COMPONENTS INSTALLED L SPILL BUCKET J STRIIiKER PLATFIBOTTOM PROTECTOR 4.CONTAINMENT SUMP paJt 95&kc CONSTRUCTION TYPE 1 SNGLE WALL 0 10 A DPL 0 99 II R(3 ERS E NMF ❑ 2 DOUBLEWALL 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1 STEEL 0 4 FIBERGLASS STEEL COMPONENT PROTECITON 0 2 SACRIFICIAL ANODE(S) 0 4•IMPRESSED CURRENT 0 61SOLADON ,tfE J470. LAG ';APPLLC iT- LFtNATURE CERTIFICATION:I certify that this UST system Incompatible with the hazardous guhstance Stored and that the Information provided herein is true,accu and lu Lull com liance with le al re ulrements. APPLICANT SIGNATURE DATE APPLICANT NAME(print) 471' APPLICANTTITLE 411. UPCF UST-B-1/2 Rev.(12/2007) /L