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UNIFIED PROGRAM CONSOLIDATED FORM / ,)1 UNDERGROUNDSTORAGETANK � r/0/lo OPERATING PERMIT APPLICATION-TANK INFORMATION (One form Per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections I,IL/it 1P,and A below) 430. 1.NEW PERMIT ❑ 3.RENEWAL PERMIT 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 5.CHANGE OF INFORMATION DATE UST PERMANENCY CLOSED: 4 S.UST REMOVAL DATE EXISTING UST DISCOVERED: eJt--15-�C 430t, FACILITY ID#(Agency Use Only) I. FACILITY INFORMATION BUSINESSl{ - - L G (Same as Focili Namew DBA-Doing Bruiness As) BUS SS SITE ADDRESS A�i ro to 3. 103. CITY 104. Dw IL TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. Q^Q TANK CONFIGURATION:THIS TANK IS 434. C)��(J(� .I^�NM�a.'57WN4- q �`I.A STAND-ALONE TANK Compl<leoM page faruch DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 2.ONE INA COMPARTMENTED UNIT comps t fa d v k 436 NUMBER OF COMPARTMENTS IN THE UNIT 437. III. TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ I6.MARINA FUELING �,9.CHEMICAL PRODUCT STORAGE ❑ Ic.AVIATION FUELING 439. ❑ 6.OTHER GENERATOR FUEL 0 4'HAZARDOUS WASTE(Includes UsW Oip ❑ 5.EMERGENCY GENERATOR FUEL IHSC$2R81.5(e)1 ❑ 95.UNKNOWN ❑ 99.OTHER CONTENT$ PETROLEUM: ❑ le,REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED IS 439. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 16.PREMIUM UNLEADED 440. ❑ 8.PETROLEUM BLEND FUEL ❑ 6.AVIATION GAS NON-PETROLEUM: 7.USED OIL $9.OTHER PETROLEUM(Specify): Sf.j -1 O IW�/ Or ry _440a ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN PRIMARY CONTAINMENT ".STEEL ❑ 3,FIBERGLASS a43. ❑ 7.STEEL+INTERNAL LINING 6.INTERNAL BLADDER 4A4 SECONDARY CONTAINMENT 1.STEEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 494a �! ❑3.FIBERGLAS$ ❑ 6.EXTERIOR MEMBRANE LINER 11 7,JACKETED [1 go.NONE ❑ 95.UNKNOWN 1199.OTHER(S ify): OVERFR,L PREVEN770N ❑ I.AUDIBLE It VISUAL ALARMS445a 3.FILL TUBCS-vALVE ❑ 4.TANK MEETS REQUIREMENTS FO❑R EXEMPTIOZ.OALL N FROM OVERFIAT LL PREVENTION EHUT-oFFQ UIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 1.SINGLE WALL ❑2.DOUBLE WALL ❑ 99.OTHER SYSTEM TYPE --&LPRESSURE ❑ 2.GRAVITI' PRIMARY CONTAINMENT -M STEEL - ❑ 3.CONVENTIONAL SUCTION ❑ q.SAFE SUCTION 1'-3 CCR i1636(03g 458. ❑ 4.FBERGLASS a"8.FLEXIBLE ❑ 90.NONE ❑ 95 UNKNOWN ❑ 99,OTHERS IO.RIGH PLASTIC 469. SECONDARY CONTAINMENT - ( °"'f3)' 464a ❑ L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 90.NONE 95.UNKNOWN ❑ 10.RIGID PLASTIC 4M6 PIPINGlFURBINE CONTAINMENT SUMP TYPE x`99.OTHER(Specify): �c.se.& v 96� ❑ L SINGLE WALL ❑ 2.DOUBLE WACL 90.NONE 4Md. VI. VENT,VAPORRECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS O 10.RIGID PLASTIC 14 90.NONE 11 99.OTHER(Specify); VENT SECONDARY CONTAINMENT a64e% ❑ 1.STEEL ❑q.FIBERGLASS ❑ 10.RIGID PLASTIC P 90.NONE (Sp.{y): M[ VR PRIMARY CONTAINMENT ❑ 99.OTHER _ 464n. ❑ I.STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC m 9p.NONE ❑ 99.OTHER(Specify): 464 VR SECONDARY CONTAINMENT ❑ VENT PIPING TRANSITION SUMP I.STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC 90 NONE ❑ 99r OTHER(Specify) ❑ 1.SINGLE WALL S 44646 TYPE : a6anL. ❑ 2.DOUBLE WALL 19 90,NONE RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) RISER SECONDARY CONTAINMENT : 464.1 ❑ 1.STEEL ❑ q.FIBERGLASS ❑ I0.RIGID PLASTIC 13 9p,NONE ❑ 99.OTHER(Specify): 4 e. FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ ;.STRIKER PLATE/BOT70M 461 01.k VIIC) . UNDER DISPENSER CONTAINMENT(UD4 CONTAINMENT SUMP 451 CONSTRUCTION TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE wALL CONSTRUCTION MATERIAL ❑ I.STEEL ❑ 3.NO DISPENSERS 90.NONE 469. ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE S O ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that thh UST system is compatible with the haardous suhstauce stored and that the iRformatlon Provided herein is true, worate and in foil com Bence with legal requirements. APPLICANT SIGNATURE DATE ago. APPLICANT NAME(print) 471 APPLICAM TITLE 4TL. UPCF UST-B Rev.(12/2007)-1/2 www.unidms.org