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• 10 O`0\ -1P UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,H,III,IV,and IX below) 430 ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: .... I DATE EXISTING UST DISCOVERED: 4306 FACILITY ID#(Agerrcv Use Only) I. FACILITY INFORMATION EOD 37523 - - BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 Axe Try BUSINESSl it ADDRES / -_ ' 103 CIT TANK ID - 3 II•TANK DESCRII'TION O�1 (,,,( 1 O TA NK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 l ` ry❑ry11 1.A STAND-ALONE TANK 39�a3Q4161 any i rvSGo p,2.ONE INACOMPARTMENTED UNIT. DATE UST SYSTEM INSTALLED 435Com aeooe 1b, a 1cont mrfnmewit (O-st I TANK CAPACff�Y IN�Gq[CONS 436 NUMBER QF CQ pgRTMENTS IN THE UNIT 437 III.TANK USE AND CONTENTS^ TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(b IoisUu Oi1) ❑ 5.EMERGENCYGENERATORFUEL HSC 8281.5(c)1 [03 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN 8 99.OTHER (Specify): I CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED [I Ic. Jr.Ic.MIDGRADE UNLEADED ❑ PREMIUM UNLEADED ❑ 3.DIESEL ❑ 5.JET FUEL [1 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL A 1'LER SR PETROLEUM eci : j B l a'Z ggpa NON-PETROLEUM:L] 7.USED OIL ❑ 10.ETHANOL ❑ IL OTHER NON-PETROLEUMS i ): 4406 IV. TANK CONSTRUCTION TYPE OF TANK 1.SINGLE WALL $2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ^L STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTER NAL LMNG ❑ 95.UNKNOWN ❑ 99.OTHER (S i ): 4g4a SECONDARY CONTAINMENT ❑ 1.STEEL 2/@3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S i ): g45a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE q5:. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑I.SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER Ore SYSTEM TYPE In I.PRESSURE ❑ 2.GRAVITY ❑ J.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION -S PRIMARY CONTAINMENT ' 'aTREL w 4,FIBERGLASS ❑ 8.FLEXIBLE ❑ In.RIGID PLASTIC' CCR§2636(a)(3)] C&1 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ f0.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): q PIPINGrrURBINE CONTAIN MENTSUMPTYPE ® LSINGLEWALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FII L PII'E PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT I.STEEL 4.FIBERGLASS ❑ I U.RIG ID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 469e VENT SECONDARY CONTAINMENT ❑ LSTEEL ® 4.FIBERGLASS 4Me1 ❑ l0.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464F VR PRIMARY CONTAINMENT ❑ 1.STEEL 400 ❑ 4.FIBERGLASS ❑ IO RIGID PLASTIC 90.NONE 99.OTHER(SPecify) 464g VR SECONDARY CONTAINMENT ❑ LSTEEL 401 ❑ 4.FIBERGLASS 10.RI GID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464h VENT PIPING TRANSITION SUMP TYPE LSINGLE WALL 40h1 2.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT ❑ 1.STEEL 04.FIBERGLASS U 10.RIGID PLASTIC JU90.NONE 99.OTHER(Specify) 40j RISER SECONDARY CONTAINMENT ❑ LSTEEL401 ❑ 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464k FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER ILAI WoOI IUM PROTECTOR 4.CONTAINMENT SUMP 4�u VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE In L SNGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90,NONE 469+ CONSTRUCTION MATERIAL ❑ 1.STEEL Q 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(S ify) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) 84.IMPRESSED CURRENT ❑ 6.ISOLATION 448, IX. APPLICANT SIGNATURE CERTIFICATION: 1 certif that ST tem is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in 11 an B i[h 1 al re uiremeats. APPLICANT SIGNATU DATE 470. APPLICANT NAME(I) 4n. APPLIC TITLE 472. I UPCF UST-B-1/2 "r Rev.(12/2007)