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0,41FIED PROGRAM CONSOLIDATED FORNrPe;1;5(00 l.0 UNDERGROUND STORAGE TANK �( OPERATING PERMIT APPLICATION -TANK INFORMATION (One fo per USST TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11,III,IV,and IX below) 430 w ❑ I.NEW PERMIT El 3.RENEWAL PERMIT ❑ S.CHANGE OF INFORMATION y\\ 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430. 1 DATE EXISTING USTDISCOVERED: -rk 0 5 yp-I q I 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ _ 1 BUSINESS NAME(Same as Facility Name or DBA-Doing Business As 3 1 S C PiY BUSINES9 SITE ADDRESS 103. CITY GG 104. IL IANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 .A STAND-ALONE TANK Complem ane page for each ❑ 2.ONE IN A COMPARTMENTED UNIT aamP em in he unit. DATE UST SYSTEM INSTALLED 435. TANK CAP ITY IN GALLONS 436- NUMBER OF COMPARTMENTS IN THE UNIT 431 h III. TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439_ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WAS'IL 0m,Wd.Used 0,10 [:15.EMERGENCY GENERATOR FUEL MSc 42528r5(c)] __ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER 439._ CONTENTS PETROLEIJM: ❑ Ia.REGULAR UNLEADED ❑ Ic MIDGRADE UNLEADED ❑ Ib PREMIUM UNLEADED a4o_ ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL .OTHER PETROLEUM(Speci ): #11, h e,%16'!n5 4404 NON-PETROLEUM:❑ 7.USED 0[L ❑ 10.ETHANOL ❑ I I.OTHER NON-PETROLEUM(S ce.f). 440b. IV. TANK CONSTRUCTION TYPE OF TANK T3 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT JS 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 4*4 ❑ 7.STEEL,INTERNAL LIMNG ❑ 95.UNKNOWN ❑ 99.OT (Specify): 444a _ ..R._. ._._.....- - SECONDARYCONTAINMENT ❑ LSTEEL ❑3 FIBERGLASS ❑ 6 EXTERIOR MEMBRANE LINER ❑ 7.JACKETED - 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445.. OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2 BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENT ION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 99 OTHER 460 ,SYSTEM TYPE ❑ LPRESSURG ❑ 2 GRAVITY ,__� 3 CONVENTIONAL SUCTION .❑ 4.SAFE,SUCTION[23 cca yz5361.x3g 458. .. _ .-PRIMARY CONTAINMENT ❑ LSTEEL ❑ 4.FIBERGLASS ❑ B.FLEXIBLE ❑ 10.RIGID PLASTIC 454. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464.. _... .... .-._ SECONDARY CONTAINMENT El STEEL [I 4 FIBERGLASS ❑ 8 FLEXIBLE [I10.RIGID PLASTIC -4646. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI. VENT,VAPOR RECOVERY (VR) AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464e] VENT SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4� VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 454 s' 51 VR SECONDARY CONTAINMENT ❑ LSTEEL ❑ 4.FIBERGLASS [I10 RIGID PLASTIC ❑ 90.NONE [192OTHER(Specify): 46hl ...._._. ... _.-._..-_.. __...-. .....-__.__.. .............. -_.__... VENT PIPING TRANSITION SUMP TYPE ❑ I SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE RISER PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): a'6a RISER SECONDARY CONTAINMENT ❑ LSTEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4�k FILL COMPONENTS INSTALLED ❑ I SPILL BUCKET ❑ 7 STRIKER PLATEBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451.< VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469. CONSTRUCTION MATERIAL. ❑ LSTEEL ❑ 4.FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 99.OTHER(Spee.ty) 4 691, VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION a48 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, accurate and in full compliance with legal requirements. APPLICANT SIGNATURE DATE 470 APPLICANT NAME(print) °tl- APPLICANT TITLE �- /^g472 UPCF UST-B Rev.(122007)-1/2 www.unid"s.org k3