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oil pg ;z 00 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK "rw 057�cl $DSS OPERATING PERMIT APPLICATION - TANK INFORMATION ( One Corm per UST) TYPE OF ACTION ( Check one item only. For an UST permanent closure or removal, complete only this section and Sections 1. 11 . Ill, Ill, and IN below) ❑ 1 . NEW PERMIT ❑ s. RENEWAL PERMIT ❑ 5 . I IANGE OF INFORMATION 1 ❑ 6. TEMPORARY UST CLOSURE ❑ 7 LIST PERMANENT CLOSURE ON SITE ❑ S . UST REMOVAL DATE USC PERMANENTLY CLOSED : 430a DATE E\[S'I'lNG UST DISCOVERED: 4iQh I. FACILITY INFORMATION FACILITY ID 9 (Agenc.r t are Onh j ! BUSINESS NA.;ME ( Same as FACILITY NAME or DBA -Doing Business As ) ' Pmt S tt � W (40 AUC) BUSINESS srrr: ')t o 13 ,21 S _ FSCALv CITY ! w It . TANK DESCRIPTION . TANK ID @ 431 16ANK MANLIFACTORER TANKCONF1GURAT1ON: TIi1S TANK IS 433, I . A STAND-ALONE TA1vK XyCES �2. ONE IN A C'0\4PARTNIENTED UNIT . complete one ma rar cads com am mit m the i mt DATE UST SYSTEM INSTALLED 05 TANK CAPACITY IN GALLONS 4.16 NiJMBI R OF COMPARTMENTS IN THE UNIT' ! ' 2 0ioo ff? ill. TANK USE AND :CONT.ENTS TANK USE If la. N40-I'OR VEHICLE FLtEL.IN'G ❑ Ib. is ARINA FUELING ❑ Ic. At lATTON FVELING 4P ❑ . CI IE\IICLL• PRODUC"1' S"rOR.AGE Q 4 , HAZARDOUS WASTE thsduies t!scq Oi4 ❑ 5 E\AFRGFYC'1' G@NERAI'OR FUEL. f4,5C' x'_5:.61 5(c)f ' ❑ 6. OTHER GENERATOR ITTEL ❑ 93 . UNKNOWN ❑ 99 OTHER (Specify): 439a CONTENTS PETROLEUM: Ia. REGULAR UNLEADED ❑ Ic. Ai1DGfcADE L'`\LLADET) ❑ lb- PRFMTUM UNLEADED •141 +. DIESEL Q 5, JET FEEL ❑ 6, AVIATION CLAS ❑ s. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (S ecifi ): 44va , NON-PEIROLEI'3t: ❑ 7. USED OIL ❑ IQ ETHANOL 1 I OTHER N01N-PErRULEU41 (Specify): 440h IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1 . SINGIJ: WALL ?. DOUBLE \\'ALL ❑ 95. UNKNOWON s4a PRIMARY CONTAINMENT ❑ 14 STEEL 3. FIBF.RGI.ASS ❑ 6, t\TERNAL BLADDER 444 ❑ T S'fEEI. > : AL LINING ❑ 9y. UNKNOWN ❑ 99. 0714I'R (Specify ). :44a SEVONDARY CONTAINMENT ❑ 1 . STEEL. X:3. FIBERGLASS 0 6. EXTERIOR mENTBRAJNE LINER ❑ 7. JA('I:GI"ED 444 ❑ 90. NONE ❑ 9i. tJNrNGAN ❑ 99. 0I'HER (S ecify): ' 4.t5a OVERFILI. PRE• VEN'T1pN f . . � UD16LE fi i`ISlf:a [. tLARNIS 3. BALL FLO_ T 3. FILL TUBE SHUT-OFF VALVE � at2 ❑ 4 , TANK \LEETS REQU'1REAILENTSFOR FXENIPTION FROM OVL•RFILI_ PREVENTION EQUIPNIL•NT V. PRODUCT / WASTE PIPING CONSTRUCTION PIPING CONSTRICTION ❑ I , SINGLE-NVALLL- D X2. DOUBLEAVALLED ❑ 99, 01"14FR t50f l Sl'S1 L- t[ T1'PL" 1 . PRESSURE ❑ 2. GR-AVIT1' ❑ 3, CONVEi�RO\AL SL`CTION' ❑ 4. SAFF SUCTION' (3? CCR .?G?6(a)(3 )) 45S PRIMARY CONTAINMENT ❑ 1 . STEEL >C4, FIBERGLASS ❑ S. FLEXIBLE ❑ 10. RIGID PLASTIC 46t ❑ 90. \ONE ❑ 95 . L!\KN011'\' ❑ 91). OTHER(Speci(vv SECONDARY CO\'TAI ."IrNT ❑ 1 . STEEL. X4, FIBERGLASS ❑ S. FLEXIBLE ❑ 10o RIGID PLASTIC 4646 1 Q 90. `ONE ❑ 95, UNKNOWN ❑ (y). OTHER (Specif6ko): 4640 PIPING%rURAtNE CONTAI.N!ME\`r SU'HP TYPE ❑ 1 SINGLE WALL 3t 2, DOUBLE WALL ' ❑ 90. ; Ut\°L• VI. VENT; VAPOR RECOVER-11. (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION 1'E\T PRIMARY CONT:V N\4ENT ❑ 1 . STEEL DK4 . FIBERGLASS ❑ 10. RIGID PL ASTIC ❑ W). \ONE0 99, OTHER tSpmil}' ) 464e k4et VENT SECONDARY CONTAINMENT ❑ 1 . STEEL 4 FIBERGLASS ❑ 111. RIGID PLASTIC Q 90. NMF FJ- 99. OTHFR (Specify-) 464f 1 461f VR PRRIARY CONI:AILN-m%JF P ❑ 1 . STEEL 2:4 . FIBERGLASS ❑ I O. RI(IID PLAS"I1C ❑ 90. > ONL ❑ 99. OTHER ( Specify) s64a 464¢ t t'R SECONDARY CONTAIN,\IrNT ❑ I STEEL FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 9(t. NO\L- ❑ 99. 01-HER (Specify) 464, 46th ! VENT PIPINU TRANSITION SUMP TYPE Q 1 , SINGLE WALL �, DOUBLE WALL El 90. NO\F 4641 RISER PRIMARY CONTAINMENT JK 1 , STEEL LJ 4, FIBERGLASS ❑ 10. RIGID PLAS11C ❑ 90. NONE Q 99. OTHER (Specify) 46•Fi •640 RISER SEC'O\DARE CONTAINMEN ❑ I STEEL §C4 . FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90, ?NONE Q 99, OTHER (Specify-) 464t- 46A t PILL COMPONENTS INST;t1..1. L"D L SPILL BUCKET >. STRIKERI'L..:VL-FBOI"I'OM PROTECTOR 2r4l, C'ON'1':LlivViL'NTSUMP 451a•c VII . UNDER DISPENSER CONTAINMENT (UDC) r( lFRTWICATION: TRUCTION TYPE ❑ 1 . SINGLE WALL 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90, NONE TRUC•11ON MATERIAL ❑ I . STEEL 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99, OTHER ( S ecifv ) 4646 c VIII. CORROSION PROTECTION L CO\•1PO?NEN I" PROTEC71ON ❑ 2, SACRIFICIAL ANODL•(S ) ❑ 4. INIPRESS[ D CURRENT ti. ISOLATION 448 IX* APPLICANT SIGNATURE L certify that this t ;S'C system is compatible with the hazardous substance stored anti that the information provided herein is true, accurate, ! and in full compliance with legal re uirentents. APPLICANT SIGNATURE• DATE 47" � Al PLICANT NAME (prim ) 471 APPLICANT TITLE - 47' , e Ut � tr` W � � p I I I ' P( " 1' USTit 1 /2 Reti'. ( 12/2007 )