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UNIFIED PROGRAM CONSOLIDATED FORM E D UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) Coe Id TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,B,111,IV,and IX belo 30 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION VI/ I�-' /„ ` ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSU=SITE8.UST REMOVA (CSC ( KDATE UST PERMANENTLY CLOSED: UST DISCOVERED: °I. FACILITYU� FACILITY ID N(Agency(Jse OnlJ) INFORMATION; - BUSINESS NAME(Same asFA CI ITY ME or DBA-Doing Business As) n On 3 1 (Poo BUSMSSqW16Q.RESS 14 w I03 CITY Q A 104 U ! IL TANK DESCRIPTION TANK ID 432 TANK MANUFACTURER 433 TANK CONFIGURATION: Hl 4i4 A STAND-ALONE TANK 2 V N [L NowIJ 2 ONE INA COMPARTMEMED UNIT Com lem one a e for each com.rcmrnt m the wit. DATE U-SrSYSTEM INSTALLED 435 TANK CAEALUYIN GALLQOIyS, 436 NUMBER OF COMPARTMENTS 1N TI IF UN 1"F 431 Til.TANK'USE DA(N,PD CONTENTS TANK USE E] 1. MOTOR VEHICLE FUELING ❑ It, MARINAFUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL BISC§2528L5(c)] ❑ 6.01 HER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.011TER (Specify): 439. CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (5 ccify)'. 440' NON-PETROLEUM.El 7.USED OIL, ❑ METHANOL ❑ II.OUERNON-PETROLEUM(S eci ): 440h IV. TANK CONSTRUCTION TYPE OFTANK ❑ I.SINGLE.WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMEN"f ❑ 1.STEEL ❑ 3.F113ERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444,1 SECONDARY CONTAINMENT ❑ L STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S ccify): 4451, OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL ILEE SHUT-OFF VALVE 452 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPT ON FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCT ION ❑ I.SINGLE-WALLED El 2.DOUBLE-WALLED El 99.OTHER 460 SYSTEM TYPE ❑ I.PRLSSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR 4263,1(,1)(3)1 459 PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ &FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(St ify): 464c PIPINGIIURBINE CONTAINMENT SUMP TYPE? ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENTPRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464, 464e1 VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 464N VR PRIMARY CONTAINMENT ❑ I.STEEL, ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464g 4640 VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL [:12.DOUBLE WALL [190.NONE 464i RISER PRIMARY CONTAINMENT ❑ L STEEL EI-4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464i 464'1 RISER SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 4Mk1 FILL COMPONENTS INSTALLED ❑ I.SPILL BUCKET ❑ 3.STRIKER PLATEIBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP ON VII.UNDER DISPENSER CONTAINMENT(UDC) CONS'I'SUCTION I)PE ❑ I.SINGLE WALT. ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 4693 CONSTRUC'I']ON MATERIAL ❑ 1.S"FEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696-c VIII. CORROSION PROTECTION STEELCOMiPONENTPROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full compliance with legal re uirements. APPLICANT SIGNATURE DATE 470. APPLICANT NAME(print) 401- APPLICANT TITLE 472. UPCF UST-B-1/2 Rev.(12/2007)