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1I-nCCK one item on ❑ 1. NEW PERMIT ❑ 6. TEMPORARY UST CLOSURE DATE UST PERMANENTLY CLOSED: as CID# Tb1k-�Z -A w.' UNIFIED PROGRAM CONSOLIDA',,aI IF - IRM UNDERGROUND STORAGE TANK IIG PERMIT APPLICATION - TANK INFORMATION (one form pel an UST pelmatlent closure or removal, complete only this section and ] 3. RENEWAL PERMIT Sections I, 11,OR111 IV, IV, and 1: ] 7. UEl 5. CHANGE OF INFORMATION- PERMANENT CLOSURE ONSITE M 8. UST REMOVAL 430e DALE EXISTING UST DISCOVERED I. FACILITY INFORMATION C fi E o DBA Doing Business As) I a. MOTOR VEHICLE FUELING 3. CHEMICAL PRODUCT STORAGE 6. OTHER GENERATOR FUEL ROLEUM: ❑ la. 0.EGULAR ❑ 3. DIESEL ❑ 8. PETROLEUM )-PETROLEUM: ❑ 7. USED OIL El I. OTHER NON L IQS. Tx '7�Z0q IP U. TANK DESCRTION ANK MANUFACTURER 433 TA NKCONFIGURATION: THISTANKIS i �Lwu. I, 1. A STAND-ALONE TANK (' �l K2. ONE M A COMPARTMENTED UNIT. Com Iveove efm esch cam eat ie the..I INK CAPACITY M GALLONS 436 NUMBER OFICOMPARTMENITS IN THE UNIT 43 III. TANK USE AND CONTENTS ❑ 16. MARINA FUELING ❑ It. AVIATION FUELING 43 ❑ 4. HAZARDOUS WASTE(Indudm Used Oil) El 5. EMERGENCY GENERATOR FUEL(HSC 425]SI.S(e)) Z 95. UNKNOWN ❑ 99. OTHER (Specify): 439 UNLEADED ❑ Ic. MIDGRADEUNLEADED ❑ Ib. PREMIUM UNLEADED 44 ❑ 5. JET FUEL ❑ 6. AVIATION GAS BLEND FUEL ❑ 9- OTHER PETRni.m rm .�--- � I ._ . - . . 4401 GNI I. STEEL IV. TANK CONSTRUCTION ---.. __..__.... ,,,,,,.- u+. unrc. ouI- AAUN l3] CCa 42536(RI ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC TYPE OF TANK PRIMARY CONTAINMENT H I. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 95. UNKNOWN �' 1. STEEL 44: ❑ 99. OTHER S eci ❑ 3. FIBERGLASS ❑ 7. STEEL+INTERNAL LINING U 6. IN BLADDER 694 SECONDARY CONTAINMENT ❑ i. STEEL ❑ 95. UNKNOWN ❑ 99, OTHER (Sped ): ❑ 3. MEI T III ❑ 6. EXTERIOR MEMBRANE g4ga OVERFILL PREVENTION LINER ❑ 7. fACKETED 99 90. NONE ❑ 95. UNKNOWN ❑ 99. pTHEA (Sped ❑ L AUDIBLE&VISUALALARMS a4s a45e ❑ 2. BALL FLOAT ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM O 451 2 DOUBLE WALL ❑ 90 NONE OVERFI PREVENTION EQUIPMENTALVE VIL NT, VAPOR RECOVERY (VR) AND RISER/ FILL V. PRODUCT / WASTE PIPING CONSTRUCTION A Non GNI I. STEEL ❑ 4. FIBERGLASS ---.. __..__.... ,,,,,,.- u+. unrc. ouI- AAUN l3] CCa 42536(RI ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 458 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER S eci 464 NMENT ❑ I. STEEL it 90. NONE ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464b ❑ 95. UNKNOWN ❑ 99.OTHER (Spmify): I AINMENT SUMP TYPEI. SINGLE WALL❑ 2 DOUBLE WALL ❑ 90 NONE 46te VIL NT, VAPOR RECOVERY (VR) AND RISER/ FILL 964d A Non and full PIPE PIPING CONSTRUCTION UPCF UST -B- 1/2 Rev. (I2/2007) - - ---- U m. KIUI0 Ft SI IC 0 90. NONE ❑ 99. OTHER (Specify) 464k FILL COMPONENTS INSTALLED ❑ L SPILL BUCKET ❑ 3. STRIKER PLATE/80TTOM PROTECTOR ❑ 4. CONTAINMENT SUMP VII. UNDER DISPENSER CONTAINMENT (UDC) 4164k CONSTRUCTION TYPE CONSTRUCTION MATERIAL. ❑ I. SINGLE WALL ❑ 2.. DOUBLE WALL ❑ 3. NO DISPENSERS 0 90. NONE ❑ 1. STEEL 469. ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 4696c VIIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate, in and full m fiance with le Ire uiremems. APPLICANT SIGNATURE DATE. 470, APPLICANT NAME (print) 471. I. 4.`ti, APPLICANT TITLE /' -4 473. UPCF UST -B- 1/2 Rev. (I2/2007)