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• ok . 1� UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One fo m per ❑ 1 (1ST) TYPE OF ACTION (Check one item only. Foran UST permanent closure or removal,complete only this section and Sections L 11,111,IV,and IX below) 430 .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: 430aDATE EXISTING UST DISCOVERED: 4306 L FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 - BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 B SINESS ITE AI S ImCITY loa 33 C Rya/S II.TANK DESCRIPTION TANK ID# �[, y�/1 /_I OqH TANK MANUFACTURER 433 TANKCONFIGURATION: THIS TANK IS 434 ❑1.A STAND-ALONE TANK 39cz�oa 3214 f�&1O.? Tr casco 2.ONE IN A COMPARTMENTED UNIT. DATE UST SY T INSTALLED 4l5 Cam ae ane Mreach com in themit. F.M,o TANK CAP CITY M GALLONS 436 NUMBER OF C MPARTMENTS IN THE UNIT 437 III.TANK USE AND CONTENTS TANK USE Rk Ia.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Mc1W.U.cd Oil) ❑ 5.EMERGENCY GENERATOR FUEL[RSC§2528L5(cp ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439. CONTENTS PETROLEUM: ❑ Is.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 .R 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 1.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S eci ): MW NON-PETROLEUM:(] 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify), 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN J42 PRIMARY CONTAINMENT 3.FIBERGLASS Cl 6.INTERNAL BLADDER❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99,OTHER (S ci ):SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ Z JACKETED❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S ecif):OVER FILL PREVENTION � LAUDIBLE&VISUALALARMS2.BALL FLOAT 3.FILLNBESHUT-OFF VALVE❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENTPRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED 2.DOUBLE-WALLED ❑99,OTHER BYSTEM TYPE LPRESSURE ❑ 2.GRAVITY ❑ I.CONVENftONALSUCTION ❑ 4.SAFE SUCTION[2l CCR S2-636(aN3)I PRIMARY CONTAINMENT �t9{{h[, 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.It PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): gbga SECONDARY CONTAINMENT ❑ L STEEL B 4.FIBERGLAS% ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): q PIPING/TURBINE CONTAINMENT SUMP TYPE 21, SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4694 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ I0.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464e VENT SECONDARY CONTAINMENT ❑ LSTEEL 46tc1 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464E VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC H 90.NONE ❑ 99.OTHER(Specify) 4648 VR SECONDARY CONTAINMENT 464 1 ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Spxify) 464h VENTPIPING TRANSITION SUMP TYPE rl I.SMGLE WALL4Mh1 2.DOUBLE WALL 90.NONE 464i. RISER PRIMARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464j RISER SECONDARY CONTAINMENT 1.STEEL 4641 ❑ 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464k FILL COMPONENTS INSTALLED4Mk1 B 1.SPILL BUCKET 3.STRIKER PLATFJBOTTOM PROTECTOR 4.CONTAINMENT SUMP 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 2.DOUBLE WALL [1 3.NO DISPENSERS 090.NONE A469a CONSTRUCTION MATERIAL ❑ 1.STEEL M 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(S i ) 4696c VIII, CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) R 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify at[h' U [em is compatible with the hazardous substance stored and that the information Provided herein is true,accurate, and In f co n i[h I al re uirements. APPLICANT SIGNATURE DATE 470 APPLICANT NAME(p' 4n. "'I"'I'C"'WiTLE C/ ..1 472. it Off, . ✓�[e UPCF UST-B-1/2 Rev.(1212007)