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AA7/R7/ UNIFIED rR®GRAM CAGNSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. Foran UST penuanent closure or removal,complete only this section and Sections 1,H,III,IV,and IX below) 430 ❑ 1.NEW PERMIT El3.RENEWAL PERMIT 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430. DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) I B / � � NA rDBA-Doing BrmmmAs) 3 L- qcCb UKTI- 7pT BUSINESS S DRESS to CITY IM III fsM E JEL TANK DESCRIPTION TANK 11)# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 4A 0 �.2.ONE STAND-ALONE OMPAR TANK TMENTED UNIT. D o 6� 2 )� '�I'�u,S �� do aro rm� i.aa� DATE UT SYS S�AI.LED 435 TANr CITY jr bon 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 ( ppOIII. ANKUSE AND CONTENTS L TANK USE a.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE llarle6o UW a0 ❑ 5.EMERGENCY GENERATOR FUEL.DISC§2msm3(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑g9.OTHER(Specify): 439+ CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED b.PREMIUM UNLEADED Z(ly/Yr°S 440 03.DIESEL ❑ 5.TET FUEL ❑ 6.AVIATION GAS ❑ &PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 490+ NON-PETROLEUM:❑ 7.USED OI. ❑ 10.ETHANOL ❑ It.OTHER NON-PETROLEUMS 440b IV. TANKCONSTRUCTION TYPEOFTANK 1.SINGLE W .DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL _ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 n 7.STEEL+INTERNAL:LINING [195.UNKNOWN ❑ 99.OTHER (S 444+ PPREVENTION CONTAINMENT `I.STEEL Q3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.lACKE1'ED 415 u 90.NONE 095.UNKNOWN ❑99.OTHER(S N5. EVENTION I.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. ❑4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERT PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION° RUCTION ❑1.SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER 1.PRESSURE ❑ 2. RAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION CCR§2636(.x3) 458 TAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Speeify): 464a CONTAINMENT ❑ L STEEL J4 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Sp.*): 464c PIPINGrrURBINE CONTAINMENT SUMP TYPE 111.SINGLE WALL [12.DOUBLE WALL ❑ 90.NONE 46/d VI VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT U 1.STEEL g,4.FIBERGLASS El 10.RIGID PLASTIC E3 90.NONE 0 99.OTHER(Specify)0464gi . 1 VENT SECONDARY CONTAINMENT I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑90.NONE ❑ 99.OTHER(Specify) f VR PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OIIBR(Spm*) VR SECONDARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS 10.RIGIDPLASTIC 90.NONE 99.OTHER(Specify)VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL .NONERISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS I0.RIGID PLASTIC W.NONE 99.OTHER(Specify)RISER SECONDARY CONTAINMENT I.STEE4.FIBERGLASS 10.RIGIDPLASTIC 90.NONE 99.OTHER(Specify)FILL COMPONENTS INSTALLED L SPILL BUCKET .STRam PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE I.SINGLE WAIL FL.DOUBLEWALL ❑ 3.NO DISPENSERS 1] 90.NONEjaccierstWe, CONSTRUCTION MATERIAL 1.STEEL 4.FIBERGLASS l0.RIGID PLASTIC ❑ 99.OTHER(S Ty)Vill. CORROSION PROTECTION STEEL COMPONENT PROTECDON ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT .ISOLATIONIX. APPLICANT SIGNATURE CERTIFICATION: I certify tha this UST system V mpatible with the haardom substance stored and that the information provided herein is tr and in full Bance w ulm,nents. APPLICANT SIGNATURE DATE / /.� O U 470' APPLICANT NAME(print)r s��f 0C)v /, f�l, 47I. APPLICANT TITLbU 4n LyUPCF UST-B-1/2 °