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f u UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK �_ �'�23 IA Ot OPERATING PERMIT APPLICATION-TANKuINNFO�roar 3 B(O IV, �v (( TYPE OF ACTION (Check one it4an poly. Foran UST permenem cbe4oe ar removal,coniplete only ❑ 1.NEW PERM 1 ❑ 3.RENEWAL PERMIT S.CHANGE C F INFORMATION 6.TEMPORAR UST CLOSURE 7.UST PERMANENT CLOSURE ON STTE S.UST REMO VAL DATE UST EWLY CLOSED: 4 DATE EXISTING UST DISCOVERED: eJOb 11 L FACILITY INFORMATION FACILITY ID#(Ag kyUse Oofy) _ _LE:f 1l / 1 BUSINESSN (Sante ee FACILITY NAME or DBA-Doing Business As) / b 3 BUS 33 103 CITY . 104 ( II TANK DESCRIPTION TANK ID N432 TANK MANUFACTURER 4J3 TANK CONFIOURA71ON:THS TI.NK IS 434 I.ASTAND-ALONETANK V ,J �� .ONEINACDOIPARTbSN7E 0 UNIT. one COMP ntlr4,ll _ DATE UST SY INSTALLED 433 TANK (1'Y IN ALIGNS 43 NUMBER OF COMPARTl1QF ITS IN THE UNIT 417 DI4 T USE AND CONTENTS - I TANK USEI MOTOR VEHELE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATIOt PURLING 439 J. HEMEAL PRODUCT STORAGE [34.HAZARDOUS WASTE(haetln Used 011) ❑ S.EMERGENI:Y GENERATOR FUEL II 31C825nI.5(,H O 6. GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER 0paaofy}. 41% CONTENTS PETR ❑ Ln.REGULAR UNLEADED ❑ Ip.MIDORADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 [13.DIESEL ❑ S.TET FUEL ----13 6. ❑ 8.PETROLEUM BLEND FUEL 9.073®R PETROLEUM . O C 440, NON- LEUM: 7.USED OIL --I0, 11.OTHER NON-PETROLEUM 440b IV. TANK CONSTRUCTION TYPE OF TANK L SINGLE WALL 2.DOUBLE WALL 95.UNKNOWN 443 PRIMARY CONTAIUM NT 1.STEEL p 3.FIBERGLASS U 6.INTERNAL BLADDER _ 4N 7.STEEL+INTERNAL LINING [195,UNKNOWN 99.OTFIPE siCy): 444. SECONDARY CONT T 1.STEEL .FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER 0 7.JACKETED 445 90.NONE 95.UNKNOWN ❑99.OTHER(Spacify): 445. OVE2ymLPRBVWf I.AUDI BLEBVSUALALARM3 2.BALL FLOAT 3.FILL TUBE SBU[OPF VALVE 431 [14.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION BQUE IMBW V. PRODUCT/WASTE PIPING CONSTRUCTION ' PIPING CONSTRU E3 I.SINGLE-WALLED CrZ DOUBLE-WALLED Q 99.OTHER 460 SYSTEM TYPE .PRESSURE 2.GRAVITY 3.CONVENTIONAL SUCTION U4.SAFI'.SUCTION In CCR4263Mi 004J8 PR84ARY CONTA NT U L STBBL 4.FIBERGLASS 8.FLEXIBLE IB RK ID PLASTIC 1790.NONE 95.UNKNOWN 099.OTBER( _ 464, SECONDARY CONTAI mamr 1.STEEL 4.FIBEROLASS U S.FLEXIBLE E3 10.RK 8)PLASM 464b ❑ 90.NONE ❑ 95.UNKNOWN 1199.OTHER(S ): _ 1444 PIPIIGRURBINR CO AINMENT SUMP TYPE JR 1.SINGLE WALL U 2.DOUBLE WALL El 90.NOQ 4E 4W .VENO,!APOR'R6CO (VR)AND RISER/FILL PIP$PIPING COr ISTRUCTION VENT PRIMARY CO INMENT 1.STEEL 4.FIBERGLASS 10.R10m PLASM 90.NONE 99.OTHER(Spedfy) 464. 464n1 VENT SECONDARY C(NTAINMEN'C 1.S7ERI. 4.FIBERGLASS III.RIGn)PLASTIC 90.NONE 99.OTHRR(Spmdf•) 4Mf 46M VR PRIMARY CONTAI 1.STEL. 4.FIBERGLASS 10.RIOID PLASTIC 90.NONE 9q.OHER(Sw*) 4646 VR SECONDARY COTe AINMENT I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC '90.NONE 99.OTIIPR(Spat*) 16Wt VENT PIPING 7RANS110N SUMP TYPE I.SINGLEWALL 2.DOUI2WALL 90,NONE RISER PRIMARY CON AMMENT .STEEL ,4.FIBERGLASS 10.MIDPLASM W.NONE 99.O HER(Speda) 46y RISER SECONDARY C4 NTAINMENT 0 I.STEEL 0 4.FIBERGLASS U 10.31100 PLASTIC A90.NONE 99.OTHER(Spmfy) 46/k _ 1 FILM.COMI'ONEMS f. ALLED 1.SPRL SUCKET 3.STRBCER PLATEIWTTOM PROTECTOR Cl 4.CONTI3NMEN7 SUMP 451aa VIL UNDER)DISPENSER CONTAINMENT(UDI), - COOiSTRUCTgN TYP 1.SINGLE WAIS. ❑ 2.DWBLE WAIL ❑3.NO DISPBN:IERS ❑ 90.NONE 46% CONSTRUCTION MA 1.aLk 4.FIBERGLASS 10.R10IB PLASTE 99.0THER eaR') VIII CORROSI PROTECTION STEEL COMPONENT ON O 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.1SOLAMN 448. DC. APPLICANT SIGNATURE CERTIFICATION: certify that this UST systems is with the haandew seMtaoce stored and Nut the Wma tle,.provided herab, a Rue.secarate, ad in fell compbaw whir APPLICANT SIGNA URE / DATE 41. 411 APPLICANT TYTLE Cl ail. APPLICANT NAME riot) / /y �y � UPCF UST-8-112 k,V.(122007)