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0 • C&-:PrAAJ v UNIFIED PROGRAM CONSOLIDATED FORM L UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) K� TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,III,N,and IX below) MOM ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4J0s I DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) I BUSINESS NAME(Scone as FACILITY NAME or DBA-Doing Business As) 3 1 �1I 1167L o u BUS SS SITE ADD RESS 103 CITY 3 3 o '"1'Ul� Cir ►a Lf M ✓} ECr1^ _ 104 IL TANK DESCRIPTION 1'i TANK ID# At 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 O`w^�N� ��I [11.ASTAND-ALONE TANK TA 01 60 O y V V yq [12.ONE IN A COMPARTMENTED UNIT. C Iaeone fasmch aainthewul. D TE US S STE IN TALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS M THE UNIT 437 112 �f 00 M.TANK USE AND CONTENTS TANK USE Ia.MOTOR VEHICLE FUELING [IIb.MARINA FUELING ❑ IC.AVOITION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE@mlada Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[ECSC 425281.5(c)l ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 43% CONTENTS PETROLEUM: la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 4a0a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ II.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ I.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ ".OTHER (S i ): a4m SECONDARY CONTAINMENT ❑ 1.STEEL qt3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE El 95.UNKNOWN 11O "5. (S ): 445. OVERFILL PREVENTION 1.AUDIBLE d VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED 2.DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION [1 4.SAFE SUCTION C23 CCR 12636(.X3)] 458 PRIMARY CONTAINMENT ❑ I.STEEL P 4.FIBERGLASS ❑ &FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE El 95.UNKNOWN ❑ 99.OTHER(Specify): 464. SECONDARY CONTAINMENT ❑ 1.STEEL OF 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING?URBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90,NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL 194.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464. 464.1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL IGI 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f �{ 4Mn VR PRIMARY CONTAINMENT ❑ 1.STEEL Ix4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.0THER(Specify) 464g 464d VR SECONDARY CONTAINMENT ❑ LSTEEL 4.FIBERGLASS L3 10.RIGID PLASTIC 90.NONE ❑ ".OTHER(Specify) 464h 464hi VENT PIPING TRANSITION SUMP TYPE I.SINGLE WALL [3 2.DOUBLE WALL 90.NONE 464i. RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS Lj 10.RIGID PLASTIC Li 90.NONE 0 99.OTHER(Specify) 4641 464'1 RISER SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464k X kl FILL COMPONENTS INSTALLED LSPILLBUCKET 3.STRIKER PLATUBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451ac VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE I.SINGLE WALL 2.DOUBLE WALL ❑ 3.NO DISPENSERS [1 90.NONE 469. CONSTRUCTION MATERIAL ❑ 1.STEEL gL4.FIBERGLASS 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448. DI. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST Sys is comp ble with the hazardous substance stored and that the information provided herein is true,accurate," and in full cause1 al re rem s. APPLICANT SIGNATURE - DATE 476. r APPLICANT NAME(print) - APPLICANT TITLE d /t/l� 4n. UPCF UST-B-1/2 Rev.(12/20117)