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ale j UNIFIED PROGRAM CONSOLIDATED FO OUNDERGROUND STORAGE TANK PERATING PER MIT APPLICATION-TANK INFO TYPE OF ACTION',,- (Check one ixassessm Y. For m UST .ON(O� >7 ❑ I.NEW PERM f Penns em closure m removal,complete only this whop and Soctq Is I,q III.IV,and IXJow) ap 3.RENEWAL'PERMIT 0 S.CHANGE )F INFORMATION 3 6.TIST PERM, UST CIASURE 7.UST PERMANENT CLOSURE ON SITE DATE UST PERM NENTLY CLOSED: al 8.UST REAM)VAL DATE EXISTING LIST DISCOVEREC: - 430E FACILITY ID aA L FACII IT Y INFORMATION N(AS Use Ontyj BUSINESS NA ' 'I, - 7 7 / 1 �$allle 89 C ITY E or DBA-Doing Businaes Ae) 6 �. 3 BUS SITE TANK ID a 43) II.TANK DESCRIPTION TANK MANUFACTURER a3) TA NK CONPIOURA7ION:TtOS T 3NKf5 434 1 ❑I.A STAND-ALONE TANK .ONEINACOt4ARTMENTIDUNrr. DATE UST SYS INSTALLED 435 TANK AP AC YIN GALLO S 436 Com exons rwwd+e. msaadc NUMBER OF MPARTMEI ITS IN THE UNIT 437 III.TANK USEAND CONTENTS TANK USE 1 MOTOR VBHICLH FUEWNG ❑ Ib.MARTA FUELING 0le.AVIATHD'FUELING - 3. HEMICAL PRODUCT STORAGE 0 4.HAZARDOUS WASTE(b dud.Lhed 00) a39 0 6. HER GENERATOR FUEL ❑ 93.UNKNOWN 0 S.EMEROENi'Y GENERATOR FUEL +Sr W3sI.Rc)I CONTENTS PHTR LEUM: )y G 0 99.OTHER (E wit); q)pa UNLEADED ❑ la MIDCRADE UNLEADED 3.D®3 ❑ Ib.PREMIUM UNLEADED 440 ❑ S.3ETFUEL 0 6.AVIATION SAS OLBUM BLEND FUEL ❑ 9,pTHHR PETROLEUM 4a0a NON-,ETAOLEUM:07.USHO OIL 10.8THANOL - I I.OTHBR TROLEUM(Spectly): 4401, S IV. TANK:CONSTRUCTION TYPE OF TANK 1.STGLE WALL 2.DOUBLBWALL Al UNKNOWN PRRHARY CONTARVM NT 0 ..STEEL 3.FIBERGLASS 0 6.I918RNALBLADDBR 3 t 7.STEEL+INTERNAL LINING 95.UNKNOWN sae SBCONDARYCONTA MENT 1.STEEL 099.OTHHR S c*): _ 444. 7.FIBERGLAS$ 6.EXTERIOR MEMBRANE LINER 7.1AL'KHTED a4s OVERFILL PREVENTI 90.NONE 93.UNKNOWN 99.OTHHR(S q� 1.AUD®LH&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT.RF VALVE a3T ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL VANTION EQUIP WENT V. PRODUCT I WASTE PIPING CONSTRUCTION PIPING CONSTRUCTIO 0 1.SINGLE-WALLED .DOABLE-WALLFD 99,01H8R SYSTEM TYPE 1.PRESSURE 2.ORAVI I T 3.CONVENTIONAL SUCTION 4.SAFE SUCTION D3 CCR 1z67H.0 1) 451 PRIMARY CONTA[hT4H 1.ST¢BL 4.FIBERGLASS 8.-FLEXIBLE 10.RIOT)PLASTIC 464 ❑ 90.NONE S.UNKNOWN 0 99.OTH S ): q46 SECONDARY CONTAIN ENT 1.STEeL 4.FIBERGLASS 8.PLEXIBLE 0 90.NONE 10.R IOIU PLASTIC 169b ❑ 95.UNKNOWN ❑99.OTFIEA(3 ci ): a64, P@TGrrNiBlNp CONT INMBNTSUMP TYPE L SINGLE WALL 2.D(3flBLH WALL 90.NON:: _ 4 d VENT;VAPOR RECOVERY(VR)AND RISER/FILL;PIPE PIPING CON iTRUCTION VENTPRIMARY CO U 1.STEEL A 4.FIBBRGLA35 U 10.RIGID PLASTIC U 90.NONE ' 13 99.OTHER(Speeify) 46411 VENT SECONDARY CO AINMENT I.STEEL 4.FIB8RGLA55 10.RIGID PLASTIC 90.NONE 9+.OTHER S eci -14641 4M., f p b> VR PRIMARY CONT I.S'TBHL 4.FLBERGLA93 10.RRIID PLASTIC 90.NONE 9+.OTFIER(Speer)VRSECONDARYCONT NT 1.STEEL 4.FIBERGLASS 10RIGID PLASTIC 90.NONE 96 OTHER(Spec*)VENT PIPING TRANSITI 1.SLNOLeWALL 2.DOUBLEWALL .NONE '-RISFR PRIMARY COM MEM I.STEEL 4.FIBERGLASS 10.RAID PLASTIC 90.NONE 9.l OTHER(Specib)RISER SECONDARY CO AINKEM 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC .NONE 9!t OTHER(SpaciO)FICL COMPONENTS 1•ED 1.SPI..HUCKET 3.STRIKER PLATA/BOTTOMPROTECTOR CCONTZM@1TSUMP VII.UNDER DISPENSER CONTAMMENT.(UI)p CONSTRUCTION TYPE W 1.SINGLE WALL 0 2.DOUBLE WALL 0 3.NO DISPENSERS 0 90.NONE 46% CONSTRUCTION MATER AL L STEEL C1 4.FIBERGLASS W.RIGID PLASTIC 99.OTHER(S fy) be 3 VIII. CORROSION ROTECTION [APPLICANT EL COMPONENT PR ON :[32.SACRIFICIALANODE(S) 04.IMPRESSED CURRENT ❑ 6 =LATIOK 448. IX. APPLICANTSIGNATURERTIFICATION: 1 c that UST system is compatible with the huardous substance stared and that the infonmat on provided herein I rue,accualq an th f ane reulremems. PLICANT SIGNA •� DATE NAME t) APPLICANTTITLE UPCF UST-B-1/3 Rel Izail )