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9 l -rA UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form M Us rDALT'EUST E OF ACTION (Check one item only. Fm an UST permanent closure or removal,complete only this section and Sectioro I,It III,N,mId IJf below) 470 .NEW PERMIT ❑ 3.R04EWAL PERMIT ❑ 5.CHANGE OF INFORMATION TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE S.UST REMOVAL PERMANENTLY CLOSED: 4308 DATE EXLSTING UST DISCOVERED:I. FACILITY INFORMATIONID A(agencyUttOnly)NAME(Same ITv N or DBA-Doing Business As) 3 A.0 BUS SITE AD REBS Im IN II.TANK DESCRIPTION TANK ID g 431 TANK MANUFAZ 133 TANK CONFIGURATION: TIBS TANK IS 434 �I ❑1.A STAND-ALONE TANK r 2.ONE M A COMPARTMENTED UNIT. DATE UST SYSTEM INSTALLED U3 TANK CITLONS +36 arum �mm�mr OF COMPARTMENTS IN THE UNIT 137 M.TANK USE AND C TANKUSE �EkIa MOTORVEHICLEFUELJNG ❑ 1b.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.11AZARDOUS WASTE(Imdu all ❑ 5.EMERGENCY GENERATOR FUEL ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER IMC pSVLXeI UA CONTENTS PETROLEUM: ❑ y REGULAR UNLEADED lc.MIDGRADE UNLEADED ❑ 16.PREMIUM ): UNLEADED Ho 3.DIESEL 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 430, NON-PETROLEUM:❑ 7.USED OI. I0.ETHANOL ❑ 11.OTHER NON-PETROLEUMS Nae IV. TANK CONSTRUCTION TYPEOFTANK ❑ 1.SINGLE WALL2.WUBLE WALL ❑ 95.UNKNOWN Nl PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 4th ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN [3 99.OTHER (Specify): 444 SECONDARYCONTAINMENT ❑ 1.STEM, .FIBERGLASS ❑ Z.EXTERIOR MEMBRANE LINER D 7.JACKETED N3 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHERS ' NL OVERFILL PREVENTION `&L 1.AUDIBLE&VISUAL ALARMS 0 2.BALL FLOAT 6 3,FILL TUBE SHUT-OFF VALVE 451 ❑ 4.TANK MEETS REQUIBEJMNTS FOR EXEMPTION FROM OVERFILL PREVENTTON EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCDON ❑1.SINGIBWALLFD 2.DOUBLE-WALLED ❑99.OTHER 468 SYSTEM TYPE .PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION L23CCR 206(4)(3)) 454 PRIMARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(5 ify): 46e4 SECONDARY CONTAINMENT ❑ 1.STEEL4.FIBERGLASS L18.FLEXIBLE ❑ 10.RIGID PLASTIC 46ee ❑ 90.NONE 95.UNKNOWN ❑ 99.O'1TRlt(S 461c PIBING/IURBINE CONTAINMENTM SUP TYPE ❑ 1.SINGLE WALT. 2.DOUBLE WALL ❑ 90.NONE 4W VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL 4.FBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464 e6 l VENT SECONDARY CONTAINMENT 1.STEEL 1.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 46l[ Nen VR PRIMARY CONTAINMENT 1.STEEL Tj 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Spedfy) 4646 46 I VR SECONDARY CONTAINMENT 0 1.STEEL 51,4.FIBERGLASS 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Spadfy) 464 4641 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL1.DOABLE WALL 90,NONE 4Ni. RISER PRIMARY CONTAINMENT 1.STER U 4.FIBERGLASS 10.RIGID PLASTIC LHJ %.NONE U 99.OTHER(Spaifj) 464j RISER SECONDARY CONTAINMENT I.STEEL 19,4.FIBERGLASS 11 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER464iI(Specify) 464 4641 FILL COMPONENTS INSTALLED I.SPILL BUCKET 3.BTRIKER PLATE/BOTTOM PROTEC[OR 4ftYcoNTAnnMENTsUO 431.-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ I.SINGLE WALL r5,2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 4694 CONSTRUCTION MATERIAL. ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 99.OTHER e6sb-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 4+4 DL APPLICANT SIGNATURE CER7MCATION: 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. APPLICANT SIGNATURE DATE 470 APPLICANT NAME(print) 071 1 APPLICANT TITLE 4n UPCF UST-B-I2 Rev.(12/2007)