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I('f 7ta1C t<J 2 Z/MS UNIFIED PROGRAM CONSOLIDATED FORM 0-OPERATING STORAGE TANK I x I a �1 OPERATING PERMIT APPLICATION-TANK INFORMATION(One form UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,I,III,IV,and IX below) ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT S.CHANGE OF INFORMATION LCI 6.TEMPORARY UST CLOSURE 7.USE PERMANENT CLOSURE ON SITE S.USE REMOVAL DATE USE PERMANENTLY CLOSED: 430' DATE EXISTING UST DISCOVERED: 4� I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Busiress As) 3 w/NC CDUKTAe l STAT/0,a. BUSINESSS E DRESS 103 CITY IN III ��M bs II.TANK DESCRIPTION TANKED# // 432 TANKMA/N[J�ACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 ?p- O 5-C)6� 2-b ! I � I/LS ❑1.A STAND-ALONE TANK ONEIN . A COMPARTMENTED UNIT. ee OM lorerh in Ow umt DATE UT SYS T ALLED 43s T CA�OITy r,L 0 O 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 M.TANK6USE AND CONTENTS TANK USE a.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ I..AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Waats UW at) ❑ S.EMERGENCY GENERATOR FUEL(HSC 125281.5(,)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 43% CONTENTS PETROLEWy 0 Ia.REGULAR UNLEADED ❑ la MIDGRADE UNLEADED Ib.PREMIUM UNLEADED 440 /f(.- DIESEL ❑ 5.JEr FUEL ❑ 6.AVIATION GAS W1`b)24cf 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM $ ' 4/0a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUMS 4406 W. -TANK CONSTRUCTION TYPE OF TANK 1.SINGLE WAL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL _ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN [199.OTHER (Specify): 444 SECONDARY CONTAINMENT1.STEEL LJ 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 u'90.NONE 95.UNKNOWN ❑99.OTHER(Specify), aaA OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-0FF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION 0 4.SAFE SUCTION 123 OCR 12636(aX3) 458 PRIMARY CONTAINMENT ❑ 1.STEEL J#4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE El 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL A4.FIBERGLASS [18.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464, PIPINGfrURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL 0 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 L STEEL 4.FIBERGLASS 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 464 VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS L] 10.RIGID PLASTIC 4441 ❑ 90.NONE 99.OTHER(Specify) 464f 4640 VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 13 10.RIGID PLASTIC ❑ 90.NONE U 99.OTHER(Specify) 4648 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 4646 464h1 VENT PIPING TRANSITION SUMP TYPE 0 1.SINGLE WALL C1 2.DOUBLE WALL MWNONE 4641. RISER PRIMARY CONTAINMENT NJ.STEEL U 4.FIBERGLASS 17 10.RIGID PLASTIC LJ 90.NONE 0 99.OTHER(Specify) 464j 4641 RISER SECONDARY CONTAINMENT 1.STEEL Wk FIBERGLASS 0 10.RIGID PLASTIC n 9D.NONE 0 99.OTHER(Specify) 464k 4Mk1 FILL COMPONENTS INSTALLED OtSPILLBUCKET .STRIKER PLATAIBOTTOM PROTECTOR 4.CONTAMMENT SUMP 454. VII.UNDER DISPENSER CONTAINMENT(UDC). CONSTRUCTIONTYPE LSINGLEWALL L.. E.DOUBLEWALL ❑ 3.NO DISPENSERS 390.NONE 469a CONSTRUCTION MATERIAL 1.STEEL !.FIBERGLASS ff 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696, VftL CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT FE 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify thatthis UST system la ompatible with the hazardous substance stored and that the Information provided herein is true,accurate, and in fuI c W nee wit 1 el uirements. APPLICANT SIGNATURE - DATE 12- //� O Q 470 APPLICANT NAME()mmt)�Ay s-b67�� 3/, C a71. APPLICANT TETLL I^ TA 7, o 4n. IIPCF UST-H-12 ,)jVL! ONJIWY- "�U✓�RncV(1 C7llAB7)