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u 1Ialumina UNIFIED PROGRAM CONSOLIDATED FORM g UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form e UST) TYPE OF ACTION (Check one item Daly. Foran UST permaueot closure or removal,complete Duly ibis section and Sections I,II,III,IV,and IX below) 450 ❑ I.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST-'--,-- 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: -- DATE EXISTING UST DISCOVERED: 430b I. FACILrlYINF0RMATI0N FACILITY ID#(Agency Use Only) BUsSBYE$$NAME(Same as FACILITY NAME or DBA-Doing Business As) /��L'r:rrro �:.-r% mac.-� � tr r'{S •. 1.-i-C 1'� ?/� .✓ BUSINESS SITE ADDRESS 103 CITY h U �t II.TANK DESC ON TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 [/r�7 n �,,1 .A STAND-MANE TANK 0- ✓5/150(7- ❑2.ONE IN A COMPARTMENTED UNIT. DATE UST SYSTEM INSTALLED a3s a1. fifes[° 'n'°0 Tuve TANK CAPACITY IN GALLONS 436 NUMBER OF CpMPARTMENTS IN THE UNIT 457 III.TANK USE AND CONTENTS / TANK USE ❑ la.MOTOR VEHICLE FUELMG ❑ !b.MARINA FUELING ❑ ic.AVIATION FUELING 09 r�J 0 3.CHEMICAL ER ATORF STORAGE ❑ 4..UNKNOWN WASTE(tn<I,de Vsed Dip ❑ 5.EMERGENCY GENERATOR FUEL[HSC 425281.3(c)] {\' ❑ R6.0EUM:THER GENERATOR FUEL ❑ 93.UNKNOWN ❑Q-99 OTHER (5 i ): 459a fhM" CONTENTS PETROLEUM: ❑ 1 a.REGULAR UNLEADED ❑ 1e.MIDGRADE UNLEADED ❑ Ib.PREMIUM UN440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS C UNLEADED Z� ❑ 8.PETROLEUM BLEND FUEL .OT HER PETROLEUM 5 -Tc:) h+wTW C "N NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 11.OTHER NON-PETROLEUM(Specify): IV. TANKCONSTRUCTION TYPE OF WJ I.SINGLE WALL ❑ Z.DOUBLE WALL 95.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 7.STEEL+INTERNAL LAVING ❑ 95.UNKNOWN ❑ 99.OTHER S 4n4a SECONDARY CONTAINMENT LSTEEL ❑3.F®ERGLASS ❑ 6.EXTEAI0RMEMBRANE LIYER 7.JACKETED 445 90.NONE ❑ 95.UNKNOWN .99.0THEA S �b OVERFILL PREVENTION I.AUDIBLEB VIS UAL ALARMS 2.BAL FLOAT J.FILL TUBE HUT-OFF VALVE 452. 4.TANKMEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 1.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER Obg SYSTEM TYPE I.PRESSURE ❑ 2.GRAVFFY ❑ 3.CONVENTIONAL SUCTION 4.SAFE SUCTION U CCR$2636(aX71 438 PRIMARY C0NTAINb1EM I.STEEL ❑ 4.FIBERGLASS 8.FLEXIBLE 10.RIGID PLASTIC 464 ❑ 90.N0NE 95.UNKNOWN ❑ 99.0THER(S iy): 46a. SECONDARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC IMb 90.N0NE ❑ 95.UNKN0WN ❑ 99.OTHER(Specify): 464c PIPING?URBIVE CONTAINMENTSUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 1.STEEL Lj 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 46ae VENT SECONDARY CONTAINMENT I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464f VR PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS IO.RIGIDPLASTIC 90.N0NE 99.0THER(Specify) g aM VR SECONDARY CONTAIN.., ❑ 1.5TEEL 4.FIBERGLASS IO.RIGIDPLASTIC 90.N0NE 99.OTHER(SpeeJy) 4464h VENT PIPING TRANSITION SUMP TYPE LSINGLEWALL � 2.DOUBLE WALL 90.NONE 4641. RISER PRINWRY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGIDPLASTIC 90.NONE 9"9 ER(Specify) 464j RISERSECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4641 F011 ILL COMPONENTS INSTALLED I.SPILL BUCKET Cl 3.STRIKER PLATE/BOTTOM PROTECTOR9.CONTAINMENT SUMP 4�kl VII.UNDER DISPENSER CONTADYMENT(UDC) CONSTRUCTION TYPE ❑ L SMGLE WALL ❑ 2.DOUBLE WALL Ll 3.NO DISPENSERS 90.NONE 469. CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RICID PLASTIC ❑ 99.OTHER(Specify) 46%6 VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION a8. UC. APPLICANT SIGNATURE CERTIFICATION: f certify that this UST system is compatible with the hazardous substance stored and that The information Previded herein is true,aceurute, and in full cam Bance with 1 el uirements. APPLICANT SIGNATURE DATE 470. APPLICANT NAME(print) nsi. APPLICANT TITLE 472. UPCF UST-B-1/2 Rev.(12/2007)