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e� - 1 UNDUD PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) / TYPE UrE ACTION (Check one item only. For m UST p EWA=L t closure or renwval,complete only this section and Sections 1,II,111,IV,end U(below) ❑ I.NEW PERMIT ❑ 3.RENEWAL PERMIT 4w ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SFFE ❑ 8.UST REMOVAL U DATE UST PERMANENTLY CLOSED: 330a DATE EXISTING UST DISCOVERED: 6 L FACILITY INFORMATION FACILITY ID#(Agency Use�Y) BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) �JEShkt)"r-r v �L-1 ' r Et c ^)5 1_1 G BUSINS SIZE ADDRESS Ip3 CITY "- C- , iJ r.-a_ UW los ' u IL TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 4M I 75P NL A STAND-ALONE TANK .ONE IN A COMPARTMENTED UNIT. DATE UST SYSTEM INSTALLED 435 C a`0"e brecb in Ne wul. TANK CAPgAs IN GALLONS 4J6 NUMBER OF CO'PARTMENTS IN THE UNIT 437 Il(] III.T USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING 11 Ic.AVIATION FUELMG 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(wea.Use,010 ❑ 5.EMERGENCY GENERATOR FUEL[HSC 125281-Xc)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99 OTHER(S ify): 0% CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 E33.DIESEL ❑ 5.TET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL 9.OTHER PETROLEUM S i p� qRL NON-PETROLEUM:❑ 7.USED OIL 10.ETHANOL El 11.OTHER NON-PETROLEUM $ 4446 W. TANK CONSTRUCTION TYPE OF TANK I.SINGLE WALL U2.DOUBLE WALL 95.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER qqq 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER IS g4pa SECONDARY CONTAINMENT 1.STEEL ❑3.FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER 7.J ACKETED 445 90.NONE ❑ 95.i1NKNOWN .OTHERS ): LJak 054 OVERFILL PREVENTION 1.AUDIBLE 8 VISUAL ALARMS 2.BALL FLOAT 3.EILL NBE SHUT-OFF VALVE 452. 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION I.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑W.OTHER 40 SYSTEM TYPE L PRESSURE [12.GRAVITY 0 3.CONVENTIONAL SUCTION ❑ 4.SAFE$UCLION 3 CCR 26361a 3)l 458 PRIMARY CONTAINMENT A I.STEEL ❑ 4.FIBERGLASS S.FLEXIBLE ❑ 10.RIGID PLASTIC 461 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99. LS 46ga SECONDARY CONTAINMENT L STEEL 4.FIBERGLASS 8.FLEXIBLE ❑ I0.RIGID PLASTIC 4MI, 90.NONE ❑95.UNKNOWNC 99.OTHER(Specify): 964c PIPrNGTTURBINECONTAINMENT3UMPTYPE ❑ 1.SINGLE WALL ❑ T UBLE WALL ❑ 90.NONE 464, VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT I.STEEL U 4.FIBERGLASS IO.RIGIDPLASTIC 90.NONE 99.OTHER(Specify) 4He VENT SECONDARY CONTAINMENT L STEEL 4.FIBERGLASS 10.-RIGID 90.NONE99.OTHER(Specify) 4641 VR PRIMARY CONTAINMENT L STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4648 VR SECONDARY CONTAINMENT U 1.STEEL U 4.FIBERGLASS El 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) /64h VENT PIPING TRANSITION SUMP TYPE L SINGLE WALL 2.DOUBLE WALT, 90.NONE 464h1 RISER PRIMARY CONTAINMENT 1.STEEL 4.F®ERGLASS 464. ❑ 10.RIGID PLASTIC 90.NONE U 99.OTHER(Specify) 464j RISER SECONDARY CO. U 1.5TEEL U 4.FIBERGLASS OTHE 10.RIGID PLASTIC 90.NONE 99. R(Specify) 464k FILL COMPONENTS INS, U I.SPILL BUCKET 0 3.STRIKER PLATE/BOTTOM PROTECTOR U C CONTAINMENT SkI UMP 4*I VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER IS i ) gbgh.c VIII. CORROSIONPROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: 1 certlfy that this UST system is compatible with the harsrdous substance stored and that the information provi4kd herein is true,accurate, and'"fuB eom Bance with legal requirawits. APPLICANT SIGNATURE DATE 470. APPLICANT NAME(print) 471" APPLICANT TITLE 47 2. UPCF UST-B-1/2 Rev.(1212007)