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o D PROGRAM CONSOLIDATED FORM UUNDERGROUND STORAGE TANK2� IWC' OPERATING P IT APPLICATION-TANK INFOZform c S-0 TYPE OF ACTION ( one item only. For an UST permanent closure ar removal,complete only thio section end Sections I,q HI,IV,and IX blow) [IL NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF I VFORMATION 6.TEMPORARY U CLOSURE 7.UST PERMANENT CLOSURE ON SITE S.UST REMOVAL DATE UST PERMANE TLY CLOSED: ° DATE EXISTING UST DISCOVERED: a L FACILITY INFORMATION FACILITY ID#(Arm)Use Oily) _ _ .ij , -716 1 BUS SS AME(S mo F CI AME or DBA-Doing Businm As) 7 tt 1 BUS ESS SITE ADPR SS 1 CRY � r IL TANK DESCRIPTION TANK IDM c( 412 TANK MANUFACTURER 433 TANK MNRCIUMnON:Tens TANK B 4 ± f p.A STAND-ALONE TANK 2.ONE INACOWARTMENTEDUVIf. �aoti a.b . aM9aa. DATE UST SYSTEM 0 S-TALLED 16 NUMBOF COMPARTMENT; IN THE UNIT 437 TIL TANK USE AND CONTENTS TANK USE ❑ Is. OR VEHICLE FULLING ❑ Ib.MARINA FURLING ❑ Io.AVIATION Pt BLIND - ❑ 3.0 MICALMODUCTSTORAGE )*•HAZARDOUS WASTE(aiduda Ue.401) 05.EMERGENCY i MNERATOR FUEL RBI'aaal.rl<E ❑ 6.OT IER GENERATORPUEL ❑ 95.UNKNOWN 0 94.OTHER(Spa bk 439, CONTENTS PETROL ❑ Ia.REGULAR UNLEADED ❑ lo.MIDORADH UNLEADED ❑ Ib.PREMIUM UN LEADED NO ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATIO UM B END FUELOTHEB 9. PBTRGWUM _ «a NON-PE OLEU .USHD OIL I0.ETHANOL CrIT-OTHER NON-PETROLEUM i : - 44ab IV. TANK.cONSTRVCTION TYPE OF TANK1.SINGLe WALL 2.DOUBLE WALL 95.UNKNOWN PRIMARY COMAINME 1.STEEL 3.FIBERGLASS U 6.INTERNAL BLADDER 444 T STEEL t INTERNAL LINING ❑ 95.UNKNOWN 99.OTHER S ' rj: _ 444• SECONDARY CONTAINM 94T 0 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER U 7.)A CKETED 445 9D.NONE ❑ 95.UNKNOWN a 99.OTHER(Specify) THER5 a ' ' _ 44U OVERFILL PREVEU10N .AUDR3L8 @.VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OF F VALVE 451 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMIINT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION Iffj.SINGLE-WALLED E3 LDOUBLE-WALLED 9.OTHER 460 SYSTEM TYPE .PRESSURE 2.GRAVITY 3.C0 ENTIONAL SUCTION 4.SAFE SI FCTION l23 CCR42b36Gt i) 49 PRIMARY COM 1.STB8L 4.FIBERGLASS S.FLEXIBLE l0.RK3R) 'LASTIC 444 O.NONE ❑ S.UNKNOWN ❑ 99.OTHER(5 ci ): SECONDARY CONTAIN M L STHHL 4.P®ERGLASS 8.FLEXIBLE f0.RIGID 'LA57TC 4616 ❑ 9D.NONE ❑ 95.UNKNOWN ❑ 99.UTHER(S city): - 4649 PIPINGITURBINE COMA EM SUMP TYPE I.SINGLE WALL 2.DOUBLE WALL 90.NONE _ 4 Vt VENT,VAPORRECOVERY(VR)A"RISER/FRL.PIPE PIPIN CONY TION VENT PRIMARY COMA EM U T.STEEL464.1 4.FIBERGLASS LJ 10.RX)ID PLASTIC 0 90.NONE Lj 99.GTHHR(SowBy) 464• UARY CON T 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONH 99.OTHER(Sp-dIY) 464[ 4618CONTAI 1.STEEL 4.FIBERGLASS 10.RK)IDPLASTIC 90.NONE 99.OTImR($pwfY) 4649 RY COM I.STEEL 4.FIB8ROLA39 lO.RK)IDPLASTIC 90.NONE 99.OTN8R(SpaerW) 4601 TRANSITIO SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NONERY COMA I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC .NONE 99.OTHER(Specify)DARY CO AINMEM 1.STEEL 4.FIBERGLASS 10.RIOID PLASTIC 90.NONE 99.OTH8R(Speufy) a _ 46491 PBL COMPONENTS D$T I.SPILLBUCKET 3.s RUM PLATE(BOT7'OMPROTECTOR 4.CONTAIM48NT STRAP 431s< VII,UNDER DISPENSER CONTAD�i1NEN'C.(I)DC) _ CONSTRUCTION TYPO ❑ 1.SINGLE WALL ❑2.DOUBLE WALL 1 NO DISPENSERS ❑ 90.NONE -------- CONSTRUCTION MATER kL I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 99-OTHER S v) _ VIII. CORROSION PROTECTION STEEL COMPONENT PRO 11CTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPR833ED CURRENT ❑ 6.ISOLATION _ 448, DC. APPLICANT SIGNATURE CERTIFICATION:I Wt W9 UST ay.ten Is 4wrepatlbla with the hazardous subnacee stored sed that the InfornuW se provided herele b I'Ba,teeorat0. am d 1518 90 40 ulre6eaats. - 4 APPLICANT S[GNATU DATE J �S APPLICANT TITLE en. 1 � APPLICANT'NAME ) 47. �� J Rev 3Y20B7) UPCF UST-18-V2 I'