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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATIONIV,and IA(One form per US 0 TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section 5n CHANGE OF INFORMATION bel ) ❑ 11, 1.NEW PERMIT ❑ 3.RENEWAL PERMIT �✓ ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ® 8.UST REMOVAL 4306 DATE UST PERMANENTLY CLOSED: DATE EXISTING UST DISCOVERED:10/11/2013 1. FACILITY INFORMATION FACILITY ID#(Agency Use Only) - I / 3 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) Levand FamilyTrust 103 CITY 106 BUSINESS SITE ADDRESS Trac 47 East Eleventh Street II.TANK DESCRIPTION 434 432 TANKMANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS TANK ID# 2 ®1.ASTAND-ALONE TANK 7 unknown ❑2 ONE IN A COMPARTMENTED UNIT. Com lete one a e for each Wm o nern in the unit 437 DATE UST SYSTEM INSTAL. D 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT unknown "599- 1000 1 111.TANK USE AND CONTENTS 439 TANK 11511 ❑ la.MOTOR ROLE FUELING [I16.MARINA FUELING E] Ic.AVIATION FUELING ❑ 3.CHEMICALL PRODUC'I'Sl"ORALE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL IH$C¢252815(c)l 4395 ❑ 6.OTHER GENERATOR FUEL N 95.UNKNOWN ❑ 99.OTHER (Specify): 440 CONTENTS PETROLEUM: ❑ Is,REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ ...PREMIUM UNLEADED ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS 440a ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): unknown petrOICUM NON-PETROLEUM:❑ 7.USED OIL ❑ METHANOL 4406 ❑ It OTHER NON-PETROLEUM(SPecify): IV. TANK CONSTRUCTION 443 TYPE OF TANK ❑ 1.SINGLE WALL ❑ �.DOUBLE WALL N 95.UNKNOWN 444 PRIMARY CONTAINMENT ❑ L STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING N 95.UNKNOWN ❑ 99.OTHER (S ci 445 SECONDARY CONTAINMENT ❑ T STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 4455 ❑ 90.NONE N 95.UNKNOWN ❑99.OTHER(S eci 452 OVERFILL.PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOA7 LL' 3.FILL TUBE SHUT-OFF VALVE ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION 450 PIPING CONSTRUCTION ❑L SINGLGWALLEp ❑2.DOUBLE-WALLED N 99.OTHER 636(x)(3)] 458 SYSTEM TYPE ❑ I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SOCTION 123 CCR§2 4M PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4645 ❑ 9D.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify} ID.RIGID PLASTIC 4646 SECONDARY CONTAINMEN"f ❑ 1.STEEL ❑ 4 FIBERGLASS ❑ 8.FLEXIBLE 464e ❑ 90_NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464d PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 7.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE VI.VENT,VAPOR RECOVERY (VR)AND R1SERl FILL PIPE PIPING`CONSTRUCTION 464 VENT PRIMARY CONTAINMENT ❑ LS"FEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLAS"1'IC ❑ 90.NONE N 99.OTHER(Spcci Cy) 464e1 464f VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE N 99.OTHER(Specify) 46411 464g VR PRIMARY CONTAINMENT ❑ 7.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE N 99.OTHER(Specify) 464 1 464h VR SECONDARY CONTAINMENT ❑ 7.STEEL ❑ 4.FIBERGLASS ❑ ]0.RIGID PLASTIC ❑ 90.NONE N 99.OTHER(Specify) 4641it 464,. VENTPIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL El90.NONE as4j ❑ I.STEEL ❑ 4.FIBERGLASS ❑ I0.R[GID PLAS77C LJ 90.NONE 99.OTHER(Specify) 464 I RISER PRIMARY CONTAINMENT 6k RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE N 99.OTHER(Specify) 464k1 FILL COMPONENTS INSTALLED ❑ 1.SPILT.BUCKET ❑ 3.STRIKER PLATE@OTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a e VII.UNDER DISPENSER CONTAINMENT(UDC) 69 CONSTRUCTION TYPE N I.SINGLE WALL ❑ 2.DOUBLE WALL El 3.NO DISPENSERS FI 9(1 NONE 6-c CONSTRUCTION MATERIAL N I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OFF TER(Specify) VIII. CORROSION PROTECTION 448 STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 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 com liance with le al requirements. 470. APPLICANT SIGNATURE DATE 10/11/2013 472. 411. APPLICANT NAME(prima) Robert Marty APPLICANT TITLE Agent for Levand Property Trust Rev.(12/2007) UPCF UST-B-1/2