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lA . k^ UNIFIED PROGRAM CONSOLIDATED FORM 6l�f RTI O9q UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(011e Porro UST) _ 430 FDATE CTT N (Check one item only. For an UST permanent closure or removal,complete only this section and dASections NGE OF INFORMATION below) PERMIT ❑ 3.RENEWAL PERMIT �' PORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL elob PERMANENTLY CLOSED: 610i DATEEXLSTING UST DISCOVERED: I. FACILITY INFORMATION i FACILITY H)#(Agency Use Only) - - BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 31 In Co l -ul.(e a,( loa BUSINESS SITE ADDRESS IID CITY , lo�z �' IL TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: TIES TANK IS 434 ❑I.A ONE STAND-ALONETANK nKrLOWn • � I.. INA COMPARTMENTED TE 1.1 ce u�o,a r,arn.m tfnax unit DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF CO PARTMEN IN IN THE UNIT 437 I Ove 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 0ndwar l oil) ❑ 5.EMERGENCY GENERATOR FUEL DISC in231.5(01 439s ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN [1 99.99.OTHER(Spec CONTENTS PETROLEUM: JR Ia REGULAR UNLEADED ❑ Ie MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS a� ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (S NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 446h ❑ 11.OTHER NON-PETROLEUMS IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN a43 PRIMARYCONTAINMENT L STEEL U 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 666 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER ): 444a SECONDARY CONTAINMENT 1.STFEI. ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED as TT 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S "Is OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS I BALL FLOAT I FEL TUBE SHUT-OFF VALVE 452. e U 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑L SINGLE-WALLED X2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE I.PRESSURE Ll 2.GRAVITY ❑ 3.CONVENTIONALSUCTION Ll 4-SAFE SIIC IONIV CCR1s 3 4sa PRIMARY CONTAINMENT ❑ I.STEER. M4.FIBERGLASS ❑ 8.FLEXIBLE ❑ to.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99. ): 464a SECONDARY CONTAINMENT ❑ 1.STEEL JS 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGIDPLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER S ): 444c PIPINGT'URBINE CONTAINMENT SUMP TYPE 29 1.SINGLE WAL 0 90.NONE 4644 �e VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Spe,4) 4 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) awf elan VR PRIMARY CONTAINMENT ❑ LSTEEL g4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 13 99.0THFR(Specify) 46ta 44 I VR SECONDARY CONTA114MENC 1.STEEL ❑ 4.FIBERGLASS ❑ lo.RIGID PLASTIC 90.NONE Ll 99.OTHER(Specify) 46an 44ah1 VENT PIPING TRANSITION SUMP TYPE 111.SINGLE WALL 2.DOUBLE WALL 90. ONE 464i RISER PRIMARY CONTAINMENT 91.STEEL ❑ 4.FTBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464i 464ji RISER SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 444k "I FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATFJBOTTtOM PROTECTOR 4.CONTAINMENT SUMP 451a VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 4694 CONSTRUCTON MATERIAL. ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(S ) VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2 SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT J2F 6.ISOLATION FT' 44f. IX. APPLICANT SIGNATURE „ CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurstc, -: and in full con liamce with legal requirements. M a �.. CANT SIGN A DATE ( U an. AAgUCANT NAME( t 471' APPLICANT TITLE n UPCF UST.B-1/2 Completed Rev.(12/2007)