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J UNIFIED PROGRAM CONSOLIDATED FORM J UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form Per UST) / gMANACTION (Check one item only. For an UST pemunent closure or removul,complete only Isis section and Sections 1,II,Ili,N,end IX below) a3o I. PERMIT' ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION PORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SPIE 8.UST REMOVAL PERMANENTLY CLOSED: 4J" DATE EXISTING UST DISCOVERED: 430b L FACILITY INFORMATION ID#(Agency Use O,atyJ _ 1 S NAME(Si mee as FACILITY NAME or DBA-Doing Busmeas As) 3 VI.r-r-Cl 7--.JiSIl'E ADDRESS �-�II.TANK D ON 432 TAINIC MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 4 ^yea I.A STAND-ALONE TANK LJ 2.ONE IN A COMPARTMENTED UNrf. DATE UST SYSTEM INSTALLED 0.36 MEW tom msfa Ns mos. TANK CAPACITY GALLONS 4w NUMBER OF COMPARTMENTS IN THE UNIT 43 7�C� M.TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ It.MARINA FUELING ❑ 1..AVIATION FUELING 439 >1 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE Dnnua,a U a,q0 ❑ 5.EMERGENCY GENERATOR FUEL DISC 1252alAc)J �t ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99 OTHER(S ): 439/ CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ica MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED Ono ❑3.DIESEL ❑ 5.JET FUEL ❑6.AVIATION GAS / A n ❑ B.PETROLEUM BLEND FUEL 9,OTHERPeTROLEUM S i . M+•-lyr Or 44aa 137, NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL I I.OTHER NON-PETROLEUM(SpecifyI, W. TANK CONSTRUCTION TYPE OF TANK I.SMGLE WALL 2.DOUBLE WALL 93.UNKNOWN 443 PRN4ARY COMAMMEM t.STEEL ❑J.FIBERGLASS 6.MTERNAL BLADDER ❑ 7.STEEL INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 44q. SECONDARY CONTAINMENT 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MENt-A LMER I.JACKETED 445 90.NONE C3 95.UNKNOWN .OTHERS 0 N 445. OVEIfFILL PREVENTION I.AUDIBLE&VISUAL ALARMS 2,BALL FLOAT U 3.FR,LTUBESHUT-OFFVALVE 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT 432 V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION - 1.SMGLE-WALLED ❑2.DOUBLE-WALLED []99.OTHER SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 2l CCR§2636oax3) 490 PRIMARY COMAMMENT L STEEL ❑ 4.FIBERGLASS S.FLEXIBLE ❑ 10.RIGIO PLASTIC 46n ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. SECONDARY CONTAINMENT ❑ 1.STEEL ❑4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4641, IB 90.NONE ❑ 93.UNKNOWN ❑ 99.OTHER(Specify): 961c PIPING/TURBME CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL 0 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CON AMMEM 1.STEEL 4.FIBERGLASS 10.RIGD P: !1;; C 90.NONE 99.OTHER(Specify) 464. VENT SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS I0.RIGID PLASTIC 90.NONE4641 99.OTHER(Specify) 4641 VR PRIMARY CONTAINMENT ❑ L STEEL 4.FIBERG *111 LASS 10.RIGID PLASTIC 90.NONE 99.OTHER ISperify) 464g VR SECONDARY CONTAINMENT ❑ I.STEEL U 4.FIBERGLASS 10.RIGID PLASTIC4&1 90.NONE 99.OTHER(SpecJy) ] VENT PIP MC TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90..N NE 464]1 RISER PRIMARY COMAMMEM U I.STEEL 4.FIBERGLASS10.RIGIB PLASTIC 90.NONE 99.OTHER(Specify) 460 RISER SECONDARY CONTAI-..NU I.STEEL U 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 469k FILL COMPONENTS INSTALLED I.SPILL BUCKET 3.STRIKER PLATFJBOTTOM PROTECTOR CONTAINMENTSUMP 451..c1 VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ KEG .DOUBLE WALL ❑ J.NO DISPENSERS 90.NONE 469a CONSTRUCTION MATERIAL ❑ I.STEEL ❑ 4,FIBERGLASS 10.RIGID PLASTIC ❑ 99.OTHER IS i ) 46gb< VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 0 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: f certify that this UST system u 4rompatible with the haaardous substance stored and that the information provided herein is true,accurate, and in full com Dance with I al uirementx APPLICANT SIGNATURE DATE Oro, APPLICANT NAME(print) 411' APPLICANT TITLE 4r-. UPCF UST-B-1/2 Rev.(12/2007)