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r �7C P /7/02- D UNIFIED PROGRAM CONSOLIDATED FO MA) UNDERGROUND STORAGE TANK µ11 p((2 � OPERATING PERMIT APPLICATION-TANK INFORMATION(One fmm perUs n TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,BI,TV,and IX below) 430 1.NEW PERMIT El3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: "In I DATE EXISTING UST DISCOVERED: 4J% L FACILITY INFORMATION FACILITY ID#(Agency Use Only) I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 BUSINI'S ADDRESS w3 CITY b 1a IL TANK DESCRIPTION TAIJK III# 432 TANK MANUFACTURER433 TANK CONFIGURATION:TIS TANK IS 434 -rff �/ ` �L.J / ❑l�'11.A STAND-ALONE TANK BE ONE M A COMPARTMENTED UNIT. 6,rmd�cum m W Ire TEM INS DATE UST Y TALLED 435 TA CAPACITY 1N GALLONS 036 NUMBER OF COMPARTMENTS IN THE UNIT 437 tO c7 �- L% ;-NK USE AND CONTENTS TANK USE 91a.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 [�3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(I&i Uxd o10 ❑ 5.EMERGENCY GENERATOR FUEL 06C 1253s1.5(c)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 43% CONTENTS PETROLEUM: ❑ In.REGULAR UNLEADED ❑ lc MWORADE UNLEADED Wb.PREMIUM UNLEADED 410 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specifyy446• NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 11.OTHER NON-PETROLEUMS 44ab IV. TANK CONSTRUCTION TYPE OF TANK L SINGLE WALL ,DOUBLE WALL 0 95.UNKNOWN al PRIMARY CONTAINMENT ❑ 1IL �.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.' INTERNAL LIKING ❑ 95.UNKNOWN ❑ 99 OTHER SECONDARY CONTAINMENT H3I.STEEL �3 FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER 7.IA=-rED as ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify) : 445• OVERFILL PREVENTION .AUDIBLE&VISUAL ALARMS (�2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452 4.TANK MEETS REQUIREMENTS F EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑L SINGLE-WALLED .DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION R3 CCR 4=636(•X3)1 458 PRIMARY CONTAINMENT ❑ 1.S'IEF,1. 4.FIBERGLASS ❑ 8.FLEXIBLE 10.RIGID PLASTIC 464 ❑ 90.NONE [ ❑95.UNKNOWN ❑ 99.OTHER(Speify): Ore. SECONDARY CONTAINMENT ❑ 1.STEEL FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ff95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL MA DOUBLE WALL ❑9R NONE 464d VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT I.STEEL. 4.FIBERGLASS U IO.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Spedfy) a64e 46X1 VENT SECONDARY CONTAINMENT 0 I.STEEL .FIBERGLASS 0 10.RIGIDPLASTIC 13 90.NONE 0 99.OTHER(Specify) a64T a64fl VR PRIMARY CONTAINMENT 0 L STEEL PP4.FIBERGLASS 0 10.RfGIDPLASTIC 0 90.NONE El 99.OTHER(Specify) a6ag 464 1 VR SECONDARY CONTAINMENT 0 LSTEEL R 4.FIBERGLASS ❑ 10.RIGIDP1ASTIC 0 90.NONE 0 99.OTHER(Specily) 4646 46M1 VENT PIPING TRANSITION SUMP TYPE I.SINGLE WALL .DOUBLE WALL 90.NONE 4641 RISER PRIMARY CONTAINMENT WWI.STEEL U 4.FIBERGLASS UP10.RIGID PLASTIC HU 90.NONE U 99.OTHER(Speafy) 4641 4641 RISER SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464k 464kl FILL COMPONENTS INSTALLED 1.SPILL BUCKET Gk3.STRIKER PLATFIBOTTOM PROTECTOR W4.CONTAINMENT SUMP 451.c VIL UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCHON TYPE ❑ 1.SINGLE WALL M.DOABLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469• CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ FBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(S ) 4696c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT GK6.ISOLATION 64s- 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, and in full compliance with legal requirements. APPLICA SIGNA DATE 470. APPLICANT NA (prin \ 471. APPLICANT TITLE ( 4n. UPCF UST-B-12 1 Rev.(1=007)